SWINKEL GICAL NURSING LLUSTRATED I i I Brigham Young | i - University Library" I I Heber C* Jex Collection | m From I Call No^..|..i^.....|..0. Ace. No | SURGICAL NURSING BERTHA M. VOSWINKEL GRADUATE OF EPISCOPAL HOSPITAL, PHILADELPHIA; LATE NURSE-IN-CHARGE OF children's hospital, COLUMBUS, OHIO ScconD BDitlon, IReviseO anC> BnlargeD WITH 112 ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO IOI2 WALNUT STREET 1899 Copyright, 1899, by P. Blakiston's Son & Co. PRESS OF WM. F. FELL 4 CO., 1220-24 Sansom Street, philadelphia. TO jfranft CalDwcU, /IR.2)., IN MEMORY OF A GREAT SERVICE RENDERED THE AUTHOR. PREFACE TO SECOND EDITION. In publishing a second edition of this volume, the work has been carefully revised, and has been enlarged by the addition of a chapter on wounds and their com- plications. The nursing in special cases has been dealt with more in detail; any new method being given which in the experience of the author seems of value. The volume is written for that large body of nurses whose surgical training has been limited to small hos- pitals or to a special line of work, and whose technical education is not sufficiently advanced to enable them thoroughly to master the subject of general nursing in all its details, as presented in the more elaborate works of physicians and surgeons, with which it does not pretend to enter into competition. The aim of the author is to give a concise outline of surgical nursing in general, together with a list of antiseptic agents, the mode of preparation of the various materials used in antiseptic and aseptic surgery, and the application of splints and fixed dressings. Bertha M. Voswinkel. New York. PREFACE TO FIRST EDITION. In preparing this volume, my purpose has been to give a concise outline of surgical nursing in general, together with a list of antiseptic agents, and the mode of preparation of the various materials used in anti- septic surgery. This volume is written for that large body of nurses whose technical education is not sufficiently advanced to enable them to thoroughly master the subject of general nursing in all its details, as presented in the more elaborate works of physicians and surgeons, and with which it does not pretend to enter into compe- tition. For whatever knowledge the writer may possess on the subject of surgical nursing she is largely in- debted to the surgeons of the Episcopal and Pennsylva- nia Hospitals of Philadelphia, whose generous assistance and never-failing kindnesses were of inestimable bene- fit in her professional work. Bertha M. Voswinkel. Columhis, Ohio. TABLE OF CONTENTS. CHAPTER I. Introductory Remarks — Care of Patient — Beds and Bed- making — Operation Bed — Bed-sores — Feeding of Helpless Patients — Lifting of Helpless Patients — Ventilation — Sunlight — Duties of Nurse toward Physician — Blank for Clinical Memoranda, .... 9-16 CHAPTER II. Qualifications of Surgical Nurse — Symptoms to be noted — Causes and Kinds of Pain — Duration — Character — Expression — Pulse — Temperature — Respiration — Cough — Sputa — Decubitus — Secretions and Excre- tions— Alimentary Canal — Urine — Attitude, . . . 17-21 CHAPTER III. Antiseptics and Antiseptic Surgery. Definition — Process of Healing — Micro-organisms — Septic Intoxication — Antiseptic Solutions — Preparation of Operating Room — Table — Duties of Nurse — Prepara- tion of Patient — Green Soap Poultice — Diet previous to taking an Anesthetic — Covering of Patient — Prepa- ration of Nurse — Irrigation — Instruments — Sponges — Ligatures — Drainage-tube — Gauze for Packing — Sutures — Protective — Dressing — Bandages, .... 22-37 ix X TABLE OF CONTENTS. CHAPTER IV. Antiseptic Dressings. page Preparation of Gauze — Plain — Medicated — Emergency Dressing — Alcohol or Evaporating Dressing — Sponges — Mode of Preparation — Ligatures and Su- tures— Drainage-tubes — Instruments, 38-44 CHAPTER V. Gynecologic Nursing. Definition — Preparation of Patient for Examination — Position of Patient — Instruments — Suppositories — Tampons — Catheter — Care of Patient after Operation , 45-5 6 CHAPTER VI. Gynecologic Nursing {^Concluded). Injections — Temperature — Time of Giving — Quantity — Syringe— Position and Care of Patient — Medicated Substances Used — Table — Venereal Disease — Abra- sion of Skin, 57-61 CHAPTER VII. Hemorrhage. Circulation — Blood — Situation of Some of the Arteries — Definition — General Symptoms — Kinds — Ways of Arresting — Instruments Used, 62-74 CHAPTER VIII. Hemorrhage {Concluded). Constitutional Treatment — Position — Stimulants, .... 75-8o TABLE OF CONTENTS. XI CHAPTER IX. Wounds and their Complications. page Classification of Wounds — Management and Dressing — Constant Irrigation — Wounds of Scalp — Neck — Chest — Abdomen — Treatment of Shock — Complica- tions of Wounds — Abscess — Stitch Abscess — Kinds of Pus — Cellulitis — Erysipelas — Poisoned Wounds — Inflamed Lymphatics — Pyemia — Tetanus — Ulcers — Burns and Scalds, 81-93 CHAPTER X. Fractures — Dislocations — Sprains. Treatment of Emergency Cases in General — Definition and Cause of Fracture — Classification of Fractures — Symptoms — Compound Fractures — Difference be- tween Fracture and Dislocation — Special Fractures — Dislocation — Definition and Cause — Sprains, . . 94-106 CHAPTER XI. Nursing in Special Cases. Abdominal Surgery in General — Position of Patient — Cleansing Tube — Dressing — Bandage — Abdominal Adhesive Straps — Nourishment — Ovariotomy — Ap- pendicitis— Lithotomy and Lithotrity — Irrigation of Bladder — Suprapubic Lithotomy — Herniotomy — Lacerated Perineum — Trephining and Concussion — Tracheotomy — Intubation of Larynx — Hip Dis- ease and Excision — Amputations, 107-129 CHAPTER XII. Bandaging. Use of Bandages — Materials Employed — Dimensions — Kinds — Method of Rolling — General Rules for Ap- plying— Special Bandages, 1 30-148 XU TABLE OF CONTENTS. CHAPTER XIII. Fixed Dressings. page Plaster-of-Paris — Bavarian Dressing — Starched Bandage — Gum and Chalk Bandage — Silicate of Sodium or Potassium — Paraffin, 149-157 CHAPTER XIV. Splints and Braces. Use — Kinds — Mode of Application — Bran and Sand Bags — Extension Apparatus — Fracture Box — Preparation for Dressing Fractures — Spinal and Hip Braces, . . 158-185 CHAPTER XV. Massage, 186-190 APPENDIX A. Invalid Cookery. " Barley Water — Imperial Drink — White Wine Whey — Egg Flip — Flaxseed Tea — Beef Tea — Beef Tea and Egg — Chicken Tea — Clam Bouillon — Lemon Jelly — Beef Juice — Snow Pudding, 191-193 APPENDIX B. Nutrient Enema — Ice Poultice — Excessive Perspiration — Table of Weights and Measures — Bichlorid Table — Poisons, 194-198 APPENDIX C. Preparation of Patient for Transfusion — Normal Salt Solution — Preparation of Rubber Tissue — Kronig's Method of Sterilizing Catgut, 199-201 Index, 203-206 LIST OF ILLUSTRATIONS FIG. PAGE 1. Blank for Clinical Memoranda, i6 2. Operating Pad, 29 3. Irrigating Stand, 29 4. 5. Drainage-tubes, 44 6. Goodell's Speculum, 47 7. Fergusson's Speculum, 47 8. Sim's Speculum, 48 9. Robb's Modification of Sim's Speculum, 48 10. Cusco's Speculum, 49 11. Speculum Forceps, 49 12. Tenacula, 50 13. Sound 50 14. Volsella Forceps, 5^ 15. Sharp Curet, 5' 16. Blunt Curet, 51 17. Cervix Scissors, 52 18. Kuechenmeister's Cervix Scissors, 52 19. Sponge Tents, 53 20. Silver-plated Catheter, 54 21. Glass Catheter, 54 22. Double- current Catheter, 55 23. Petit's Tourniquet, 68 24. Esmarch's Rubber Bandage, 69 25. Esmarch's Tourniquet or Tubing, 70 26. Esmarch's Hard Rubber Compress, 70 xiii XIV LIST OF ILLUSTRATIONS. FIG. PAGE 27. Listen's Self-closing Artery Forceps, 71 28. Hemostatic Forceps, 71 29. Tenaculum, 71 30. Aneurysm Needle, • • . , 72 31. Dr. Paquelin's Cautery, 73 32. Uterine Syringe, 109 2^. Abdominal Bandage, ill 34. Abdominal Adhesive Straps, ill 35. Double Silver Tracheotomy Tube, 119 36. Golding-Bird's Dilator, 1 19 37. Trousseau's Forceps, 120 38. Collins' Tracheotomy Forceps, 120 39. Stomach-tube, 122 40. I. Intubation Tube and Introducer, 123 40, 2. Denhart's Mouth-gag, 123 40, 3. Intubation Tube Extractor, 123 40, 4. O'Dwyer's Intubation Scale, 123 40, 5. Larynx Tube, 123 41,42, Frames used in Treatment of Hip-joint Disease, . . 124 43. Frame used in Treatment of Hip-joint Disease, .... 125 44. Triangular Hip Bandage, 126 45. 46. Triangular Hip Bandage Applied, 127 47. Cradle to Protect Limb, 128 48, 49. Bandage Rollers, 133 50. Bandage Scissors, 135 51. Spiral Bandage of the Finger, 1 35 52. Spiral-reverse, of Upper Extremity, I36 53. Spiral-reverse, of Lower Extremity, 136 54. Spica, of Instep, 137 55. Figure-of-eight of Ankle, 138 56. Barton's Bandage, ... 138 57. Recurrent Bandage of Stump, 138 58. Recurrent Bandage of the Head, 138 59. T-Bandage of the Eye, 140 LIST OF ILLUSTRATIONS. XV FIG. PAGK 60. Four-tailed Bandage of the Head, 140 61. Eight-tailed Bandage of the Abdomen, . '. , . 140 62. The Square, I4I 63. The Oblong, 141 64. The Triangle, 142 65. The Triangle Folded ior Hip, 142 66. The Triangle Applied to Head, 142 67. The Cravat, 142 68. Cravat Applied to Axilla, 144 69. The Cord, 144 70. 71. Liebreich's Eye Bandage, . . 145, 146 72. Bandage of Scultetus, 147 73. Leg Incased in Plaster-of- Paris Dressing, 151 74. Posterior Plaster Splint, 153 75. Interrupted Plaster Dressing, 153 76. Plaster Saw, 155 77. Scissors for Removing Plaster-of- Paris, 155 78. Straight Splint, 159 79. Internal Angular Splint, 159 80. Acute Internal Angular Splint, 159 81. Obtuse Internal Angular Splint, 159 82. Anterior Angular Splint, 160 83. Stromeyer's Splint, 160 84. Agnew's Metacarpal Splint, 160 85. Straight Palmar Splint, 160 86. Bond's Splint, 161 87. Agnew's Splint for Fracture of the Patella, 162 88. Hamilton's Splint for Fractured Patella, 162 89. Packard's Splints for Knee Excisions, 164 90. Long Splint for Fracture of Femur [Ashkurst)^ .... 165 91. Extension Standard, 167 92. Block for Elevating Foot of Bed, 167 93. Weight, 167 94> 95 > 96. Dr. Levis's Extension Apparatus, 168 XVI LIST OF ILLUSTRATIONS. FIG. • PAGE 97. Single Fracture Box, 169 98, 99. Double-inclined Fracture Box. 169 100. Salter's Fracture Cradle or Swing, 171 loi. Molded Splints of Felt or Binders' Board, 173 102. Prof. N. R. Smith's Anterior Splint for Fractured Thigh, 174 103. Prof. Ashhurst's Splint for Resection of Knee-joint, . . 174 104. Sayre's Suspension Apparatus, 177 105. Jury-mast and Head Support, 178 106. Dr. T. W. Sloan's Method, 180 107. Spinal Jacket of Leather, 180 108. Spinal Jacket with Jury-mast, iSi 109. no. Max Wocher's Spinal Brace, 182 111. Dr. Thomas' Hip-joint Apparatus, 184 112. Taylor Brace, 185 SURGICAL NURSING. CHAPTER I. Introduction— Care of Patient— Beds and Bed-making— Preparation of Bed for Operation — Bed-sores — Feeding — Ventilation — Sunshine — Flowers — Duty of Nurse — Blank for Clinical Memoranda, No doubt the greater portion of those who will be at i„troduc all interested in the following pages will be nurses whomllks^. have passed through a certain period of training in one of the many hospitals in the land, where it often happens that the greater part of the time is spent in the medical wards, the nurse receiving very little practical surgical training. While the plan of work of both is similar, surgical work differs in many respects from medical work. In both cases the care of the patient is of the utmost importance, if the nurse is to fulfil her mission — namely, to care for and minister to the sick and afflicted. The first things upon which the comfort and well-being care of - 1 . , ■, 11. 11 j'i.- patient. ot the patient depend are cleanlmess and the condition of the bed. For this reason, whenever it is possible 2 9 lO SURGICAL NURSING. the patient should be bathed every day. If for any reason an entire bath can not be given, at least the face, hands, chest, and back should be bathed. It will be found more refreshing to add a little alcohol to the water in bathing the body, as it imparts freshness to the skin. The patient should be placed between blankets to avoid the possibility of giving a chill. A good nurse will always have everything at hand before beginning to bathe the patient, thus avoiding any unnecessary delay. Care should be taken to keep the mouth and teeth in good condition, using a little Listerine for this purpose. If the patient be a woman, the hair should be neatly braided and put out of the way. It is needless to tell a nurse to keep the nails carefully cleaned and trimmed. The ideal surgical bed should be firm and even, consisting of a good hair mattress, but without springs. In some cases, such as fracture of the thigh or excision of hip, a board is fitted to the bedstead and placed underneath the mattress, so as to give it additional firm- ness. As rest to the injured part forms the basis of all surgical treatment, it is advisable to make the bed with as little disturbance as possible. Unless it be abso- lutely necessary, the long rubber sheet should be dis- pensed with, as it proves a source of great trouble in keeping the bed free from wrinkles, and is generally uncomfortable. If used, it should be securely tied in place under the mattress. In making the bed begin at the head, tucking the sheet firmly under the head of the mattress, so that the INTRODUCTION. II weight of the body will not draw it into a mass of wrinkles under the back; then roll the remainder of the sheet, or, if preferred, fold it tightly upon itself; draw it gently under the shoulders to the hips ; raise slightly the latter and draw it over the entire mattress, stretching and tucking it firmly at the sides. The cross rubber and draw sheet should be folded together in the same manner, care being taken to keep the upper end of the same sufficiently high to have the shoulders rest upon it, so as to keep it in position. This also should be tightly stretched, and kept free from crumbs and wrinkles and perfectly dry, to pre- vent bed-sores. There is still another way of preparing the bed — viz., rolling the sheet from both ends and slipping it under the hollow of .he back, when it can be passed under the shoulders and under the hips, after which it can be tucked firmly under the mattress. In severe cases, where it is essential that the patient be disturbed as little as possible, two persons should make the bed. In other cases the patient may assist the nurse by grasping the headboard and elevating the shoulders, and with the assistance of one leg slightly raising the hips. In some cases, such as fracture of the thigh or excision of the hip, it becomes the duty of the nurse to see that the recumbent position is maintained, as a good recovery frequently depends upon it. For this reason, in some cases, — as recent fracture of the thigh or ribs, and after certain operations, — but one pillow is allowed. In injuries to the head, where bleeding is likely to 12 SURGICAL NURSING. occur, or where an ice-cap is used, the pillow should be covered with a mackintosh pillow slip. Operation In preparing a bed for a patient after an operation, if it be upon the lower extremity, the entire mattress should be covered, first, with a rubber sheet, tying it securely underneath; second, the ordinary sheet, firmly tucked ; third, the rubber draw and cross sheet, followed by a blanket and the usual covering. If the operation be a major one, after which it is not desirable to move the patient for a number of hours, it will be found very serviceable to place a small square of mackintosh covered with a piece of blanket directly under the buttocks ; this can easily be removed should an accident occur, leaving the under blanket in good condition ; a blanket sheet and the usual bedding com- plete the arrangements. The bed should be thoroughly warmed by means of hot-water bags before placing the patient in it.* Bed-sores. When a patient is obliged to lie upon his back for any length of time, great care must be exercised in order to prevent bed-sores. The skin should be washed thoroughly with Castile soap, and rubbed well, at least once a day, with alcohol and alum. If there be the slightest appearance of redness, the pressure should be * The bags should be thoroughly protected by several folds of flannel, if they are left in the bed, so that they do not come in actual contact with the patient. Unconscious patients are fre- quently burned by having the bottles too hot or insufficiently covered. INTRODUCTION. 1 3 relieved by the use of an air cushion or a ring made of oakum. The shoulder-blades and heels often have to be protected in the same manner. If, in spite of all precautions, a bed-sore forms, use broad strips of ad- hesive plaster carried across the back to relieve pressure, covering in the ulcer and the surrounding skin several inches above and below, or apply an antiseptic dress- ing. Bed-sores are especially to be guarded against in cases of paralysis, when the patient would feel no soreness, and where the constitution is seriously im- paired. As crumbs are a source of great discomfort, the feed- Feeding r 1 1 ^ • • r • mi of hclpleSS ing of helpless patients is a matter of importance. 1 he patients. neck should be protected by a napkin or towel, to pre- vent the crumbs from slipping down ', the bed should be thoroughly brushed out after each meal. All nourishment is to be given regularly by direction of the physician. If a feeding cup be used, be sure that the spout is clean. Care should be taken to have the tray arranged as daintily as circumstances will permit ; all articles should be scrupulously clean. If the patient is to be fed, do it as though it were a pleasure to you, not a task, for under the best of circumstances it is a trying ordeal. To lift a patient, slip one arm along the spine, thus Lifting 111111 1 1 patients. .supporting the head and back ; pass the other arm under the legs at about the knee-joint, firmly grasping the leg which is farthest from you. Very heavy persons are most easily lifted by standing astride of them, grasp- ing the body near the shoulders. Proper ventilation of the room or ward is also a mat- Ventiia- 14 SURGICAL NURSING. ter of importance. I liave found nothing better than Dr. Park's definition : '' Proper ventilation is clean air displacing foul air constantly and steadily without chill- ing the patient." To accomplish this in a hospital ward is a comparatively easy matter, by opening the windows a little from the top, either on one side of the ward^or the other, preferably the windward side. Under certain circumstances, of course, they may be open wide, from both top and bottom. Another very good way to insure ventilation is to have a piece of board, four or five inches broad, sometimes made with a hinge in the middle, and of the same length as the breadth of the sash-frame ; when the lower sash is raised, the board may be fitted into the space left. By this method the fresh air is admitted between the upper and lower sashes, at such a height from the floor that it will not easily create a draft. If care be taken to give extra covering to the patient, in most cases the window may be opened for a few minutes with little or no risk, keeping the additional covers until the room has regained its usual temperature, which, except in special cases, should be about 68° F. A nurse will frequently find that restlessness and inability to sleep are caused by improper ventilation. The matter of sunlight is also to be considered ; with few exceptions, such as injuries to the brain or eyes, the more sunlight the better, as, aside from its health-giving properties, it imparts a cheerful aspect to the room. Flowers also add much to the brightness of a hospital ward or a sick-room, but should always be removed at INTRODUCTION. 1 5 night, on account of the carbonic acid which they exhale. Having briefly gone over what conduces to the com- Duties of fort and well-being of the patient, it only remains to be toward said that the duties of the nurse toward the physician^ ysician. may be comprised in a few words : To report accur- ately upon the condition of the patient since his last visit, and to faithfully carry out his instructions until his return. Be careful that each direction is thoroughly understood, and never hesitate to acknowledge a mis- take if one has been made. In special cases it is well to keep clinical notes, in addition to the temperature chartSj showing temperature, pulse, respiration ; amount and character of urine voided ; number and character of stools ; number of hours of sleep ; exact quantity and kind of nourishment taken ; also medicine and stimu- lants; symptoms and local treatment. The most convenient form for keeping these notes is to rule a paper somewhat after the fashion of the illus- tration on next page, adapting it as the surgeon or nurse may prefer. i6 SURGICAL NURSING. Datb Name Page Symptoms j: Trkatmest ixciuding Timk|temp. ?i;lse'resp KeMARKS ; XOCRI^HVEN-T MED.& StIM. Local !i 1 ij 1 :: 1 'i ' ' ! ii 1 1 i i- i .1 1 1 !: 1 1 li 1 1 1 PVMMARY FOR L'+ HOURS. Temp. Ranee Pulse Rcsp. .. Slerp Nourishment Condition r,fPVii, Medicine Stimulants Urine Stools General Condition Fig. 1. — Blank for Clinic.\l Memoranda. CHAPTER ir. Qualifications of Surgical Nurse — Symptoms to be Noted — Kinds of Pain — Duration— Character — Facial Expres- sion— Changes of Pulse — Temperature — Respiration — Cough — Sputa — Decubitus or Position — Secretions and Excretions — Alimentary Canal — Urine — Gait. There are certain qualifications necessary for a surgi- cal nurse, which may be thus classified : A Good Constitution, where strength is severely ^"ns'of sur- taxed, gical nurse. Powers of Endurance, where vigilance is required. Alertness, both mental and physical. Observation, for accurate noting of symptoms. Kindness, especially in nervous cases. Pluck, under trying situations. Cheerfulness, under all circumstances. Firmness and kindness should invariably go hand in hand, for the combined display of these characteristics will often exert a good moral influence over the patient. All changes in the facial expression of the patient Symptoms should be observed. Sudden pallor or loss of color may indicate syncope, or, after operation, hemorrhage, in which case the dressings should be instantly examined. Flushing is also a noteworthy symptom ; it is often found in pneumonia, when the side of the face corre- 17 i8 SURGICAL NURSING. Kinds of pain. sponding to the affected lung is flushed. This flushing will usually be seen also in cases of facial erysipelas, first appearing over the bridge of the nose. Lividity occurs in asphyxiation, when the supply of oxygen is insufficient, or where there is an accumula- tion of carbon dioxid. Pain may be exhibited in various ways by different persons, but a pinched, drawn expression is a pretty sure sign that the patient is suffering. Pain is due to pressure upon the nerve filaments; it may be dull or aching, as when the muscles are affected ; sharp, as in inflammation of the serous membranes (pleura or peritoneum) ; burning, as in erysipelas ; shooting, as in neuralgia or meningitis; boring, as in ulceration of the joints ; throbbing, as in felon. It may be constant ; paroxysmal, as in the kidneys ; intermittent, as in neuralgia and syphilis. The character of pain changes. In the early stages of an inflammation it is throbbing, and as pus forms the throbbing increases; sometimes the tenderness may be greater than the actual pain, as in swelling of the mammary glands. It maybe acute, running a sharp course; subacute, running a less sharp course; or dull, running a slow, chronic course. Expression, in injuries to the head difference in expression may be noted in the sides of the face. Partial and tempo- rary paralysis of the facial muscles may be due to cold, and is known as Bell's paralysis. Lack of motion may herald paralysis. Duration Character. SYMPTOMS. 19 Changes of the pulse as to frequency and compressi- Pulse, bility are to be noted. In syncope the patient is nearly pulseless. In heart failure the pulse is soft and compressible. In brain compression it is slow and hard. In uremia this same condition is present, but is less apparent. In peritonitis the pulse is small, thready, and weak, sometimes disappearing at the wrist, and is accompanied by a pinched, anxious expression. The temperature should be regularly taken night and Temper 11 • ature. morning, or more frequently, as the case may require. A sudden fall of temperature occurs in shock ; sudden rise of temperature occurs in septicemia. The rate, rhythm, and character of the respiratory Respira movements should also be noted : They may be easy or labored ; slow or rapid ; stridulous, as in croup ; ster- torous, as in cerebral affections. In some cerebral affections, or at the termination of Bright's disease, a peculiar form of respiration often takes place, which is known as ** Cheyne-Stokes " breathing. The respiration ceases altogether for a time, and then recommences, being at first rapid and shallow, then deeper and slower, after which it again ceases. In pneumonia the respirations are rapid, but the pulse-beat is not proportionately increased, as in nearly all other cases. In peritonitis the respirations are shallow and fre- quent, with no movement of the abdominal muscles. In cases of dyspnea, or impending asphyxiation, the respirations become labored, the muscles of the face and neck horribly drawn, the nostrils dilated and 20 SURGICAL NURSING. flapping, and the general appearance of the patient indicates intense suffering. Cough. Cough is to be observed in old persons particularly, and in patients after taking ether. It may be a dry or hard cough, without expectoration ; a moist or soft cough, with expectoration. Besides these characteristics it is necessary to note its frequency and severity ; whether it is worse or better at any one time during the twenty-four hours. Sputa. Observe the appearance of the sputa ; whether blood be present after injuries to the chest, as fractured ribs, gunshot wounds, stabs, etc. Decubitus. Position of patient is also to be observed. In some injuries to the head where there is entire unconscious- ness, the patient will remain in any position in which he is placed. In cases of cerebral irritation and tuber- cular meningitis of children there is great restlessness, with increasing effort to bore the head into the pillow. In pneumonia the patient lies upon the affected side, to allow the opposite lung to perform its function freely. In peritonitis the knees are drawn up and the shoulders elevated, a position which tends to relax the abdominal nmscles. In renal calculus and cases of intestinal ob- struction the position is similar to that taken in perito- nitis, except that the patient endeavors to support him- self by pressure upon the abdomen. Secretions Secrctioiis and excretions are to be noted, particularly and excre- when affecting the respiratory tract. The character of the sputaof pneumonia, croup, diphtheria, and approach- ing hemorrhage should be carefully observed. The lions. SYMPTOMS. 21 sputum of pneumonia is of a reddish-brown, rusty hue. Always note the character of the stools, especially ^^Jj^f"^^'^ after all operations. In intestinal obstruction the necessity for an operation might be determined by the character of the stools. In some cases a ** telescoping " of the intestines will occur, one part being pushed forward into the other; a careful watch must then be kept of the stools to see if any mucous membrane be passed. If bright red blood be present, the attention of the surgeon should be directed to it at once. Retention or suppression should also be reported. The urine should be carefully observed after opera- Urine. tions, and, if possible, prior to them. In all cases note the quantity voided during twenty-four hours, and report the same to the surgeon. If blood be present, report at once. In selecting a sample for examination, it is usually considered best to take all that has been passed during twenty- four hours, so that a general average may be had. If this is not practicable, save a night and a morning specimen, as they may differ greatly. Attitude or gait in walking may suggest the location Attitude. of disease. In dropsy and abdominal abscess the head and shoulders are thrown back. In spinal disease the patient will endeavor to support himself by resting his hands upon his knees. Patients may feign eccentricities of gait and posture which may deceive the most skilled eye ; constant watch- fulness alone will assure the surgeon of his suspicions. CHAPTER III. ANTISEPTICS AND ANTISEPTIC SUR- GERY. Definition — Process of Healing — Micro-organisms— Sep- tic Intoxication — Aim of Antiseptic Surgery — Anti- septics IN Common Use— Preparation of Operating Room — Preparation of Patient — Diet — Clothing — Towels — Irrigation — Instruments — Sponges — Liga- tures— Drainage Tube — Sutures — Protective — Dress- ing. Definition. Whenever dead organic matter is exposed to the air, it undergoes decomposition or putrefaction, attended with the development of disagreeable odors and the evolution of gases, such as ammonia and hydrogen sul- phid. Putrefaction or sepsis is now known to be caused by the presence and activity of micro-organisms. In the putrefaction of organic matter poisonous bodies, termed ptomains, are also produced. Asepsis is a condition in which there is a complete absence of all septic material and pathogenic organisms, hence a condition the reverse of putrefaction. Aseptic surgery includes the use of all methods, such as heat and chemic agents, by which absolute cleanli- ness is obtained, with reference to patient, instruments, room, etc. After an operation only such dressings are used as have been sterilized. ANTISEPTICS AND ANTISEPTIC SURGERY. 23 Antiseptic surgery includes the same methods, but in addition employs, during and after the operation, chemic solutions and dressings impregnated with them, for the purpose of preventing the access of micro-organisms to the wound. In the healing of wounds several different stages are The pro- . . , , - , , . , cess of observed, varying with the nature of the wound, with healing. which nurses should be acquainted. All wounds are repaired by an exudation of lymph from the blood- vessels, which glues the parts together, becomes vascular and organized, and develops into fibrous tissue. When the surfaces of a recent wound are brought to- ^'''^^ "'^^"' o tion. gether and placed in perfect apposition, and no foreign body permitted to injure them, they soon become glued together, the healing process at once begins, and in a short time the line of separation is hardly visible. A union of this kind is known as union by first intention. Usually the amount of lymph is small. When the injury is much greater, and is attended by Second in- a loss of tissue, the process of healing is practically the same. After hemorrhage has ceased, the blood coagu- lates, lymph and leukocytes are poured out, the blood- vessels dilate and grow into the exudation. From all sides of the wound spring up small red vascular points, which constitute granulation tissue. This, as it in- creases, gradually restores the parts to a practically nor- mal condition. There is no inflammation or suppura- tion. This is known as union by second intention. When two surfaces of a granulating wound are per- 1 hird iu- fectly clean, and are brought into perfect apposition, the organisms. 24 SURGICAL NURSING. granulations fuse together, the blood-vessels pass from one side to the other, and union soon takes place. This is known as union by third iniention. Micro- The process of healing of any wound may be, and is, frequently interfered with by the entrance of low forms of vegetable life, which, from their minute size, are known as micro-organisms or bacteria. It is the presence and destructive influence of these organisms in wounds which give rise to inflammation, the formation of pus, and certain poisonous conditions of the blood. Notwithstanding the large number of micro-organisms, they can be classified according to their form into four groups — viz. : 1. The micrococci include all those organisms which are spheric or slightly oval in shape. Of all micro- organisms, the micrococci are the smallest. 2. The microbacteria include those organisms which are cylindric in shape, with rounded edges, or which are oval and elongated. 3. The bacilli include all those organisms which are rod-shaped, with square-cut ends. There is much varia- tion in their size and length. 4. The spirilla include those organisms which are filamentous and spiral in shape. Nearly all forms of bacteria increase by simple divi- sion, a process which takes place with extreme rapidity. Some of the bacilli propagate themselves by the forma- tion of spores or seeds, which transmit the properties of the parent organism. Micro-organisms are divided into two classes — viz.. ANTISEPTICS AND ANTISEPTIC SURGERY. 25 pathogenic and non-pathogenic. The pathogenic are those which cause specific diseases, such as the bacillus of tetanus, of diphtheria, of typhoid fever, etc. The non-pathogenic are those which, though causing decom- position, are practically harmless to the body. Healthy tissues possess the power of resisting the de- structive influence of nearly all bacteria. As soon as the vitality of any tissue or fluid is impaired, it affords a suitable nidus for their growth and development. Hence after an operation in which tissues have been injured inflammation and pus may form, followed by severe constitutional symptoms. The recognition of this fact has given rise to antiseptic and aseptic surgical methods. Septic intoxication is caused by the absorption of septk in- , , . • • i. ^1 toxicatiou. septic micro-organisms and their ptomains into the blood, rendering it putrid and highly dangerous. The symptoms which follow septic intoxication are chills, rise in temperature, nausea, vomiting, followed by col- lapse and death. Suppuration or decomposition in a wound is generally caused by the presence of certain micrococci which effect the decomposition and solution of the solids and fluids of the affected parts. Pyemia is also caused by the entrance of these micro-organisms into the blood, and is the most intense form of blood-poisoning. It is distinguished from septicemia in that it is attended by the formation of secondary abscesses. The aim of antiseptic surgery is to place a barrier Antiseptics, between the wound and these micro-organisms. This is accomplished by the use of one or more of the various 3 2 6 SURGICAL NURSING. antiseptic agents, the most powerful among them being bichlorid of mercury, otherwise known as corrosive sub- limate; next in order are carbolic acid and formal. Iodoform, boric acid, aristol, and salicylic acid are called accessories. Red iodid of mercury is sometimes used in place of bichlorid, the latter being so powerful that a solution of I : 3000 is considered strong enough to de- stroy all germs ; in actual practice i : 1000 or i : 2000 is the solution generally used for wound irrigation, a weak solution, 1 : 4000 or i : 5000, for the brain or the eye. Bichlorid There are many convenient ways of preparing bi- of mercury, , , . , , . rT-.ii • • -> chlorid solution, lablets containing 7^^^ grains may be obtained : one tablet dissolved in one pint of water will make a solution of i : 1000. There is also another solution of bichlorid in alcohol, made by adding fgj of bichlorid to one quart of alcohol, making a solution of I : 300. That most frequently used is the standard solution (gr. xv to f^j), four drams (f^iv) of which in one pint of water make a solution of the strength of I : 1000. Cor7-osive sublimate is extremely irritating, and should be used with the greatest care. A weak solution, i : 8000 or I : 12,000, should be employed for washing out large cavities. Where it has been used for some length of time, either for douching or in the form of a moist dressing, a flushing of the wound and the surrounding surface of the skin may be noticed, sometimes accom- panied by an elevation in temperature. These symp- toms will quickly subside if the drug be discontinued for a time. -ANTISEPTICS AND ANTISEPTIC SURGERY. 27 In the early days of antiseptic surgery carbolic aci'^l CarhoUc was used entirely, the steam spray being kept in constant play during the operation. It is a highly volatile sub- stance, easily inhaled, and sometimes causes intoxica- tion. A three per cent, solution is generally used. Formal is a powerful germicide, and is highly irritat- Formal, ing. A two or three per cent, solution may be used, and should be followed by a douche of sterile water. Peroxid of hydrogen is another agent which is com- P^^^^i^ of ing into very general use. It is sometimes fancifully called '* bottled sunshine." To obtain its full effect, it should be used before bichlorid. In washing out a cavity, plenty of time should be allowed for the first syringeful to come out before injecting another. Un- less there is a sufficiently large opening, it will cause intense pain, on account of the distention which takes place in the wound. It can be purchased in bottles varying in quantity from four ounces to one pound. It should be kept well corked, in an upright position, in a cool place. It is claimed to be non-poisonous, but produces a burning sensation in some cases. Boro-salicylic is highly recommended by a (Jer- Boro- J o J J salicylic. man physician named Tersch, and is composed of 2 parts salicylic acid, 12 parts boric acid, and 1000 parts of water. Boric acid is a solution which is considered per- Boric add. fectly harmless, and can be used on the most delicate membranes without causing any irritation. Boric acid gr. xv to one ounce of boiling water 28 SURGICAL NURSING. makes a saturated solution ; gr. x to the ounce is often used also. Iodoform. lodoform is a substance easily remembered by its odor, and has been extensively used in antiseptic work, although aristol or pulverized boric acid is now used for the same purpose by many surgeons. It has also been given internally for some diseases, although at- tended by more or less risk when used in large quan- tities. Used freely upon a wound, it will sometimes cause considerable irritation, accompanied by a rise in temperature. Dusted over the surface of a wound, after the edges have been brought together, either alone, or in connection with boric acid or bismuth, it acts as a protective, and forms a coating which absorbs the discharge. A one per cent, solution of iodoform in glycerin is frequently injected in deep sinuses. Iodoform in The solution of iodoform or tinct. benzoin comp. in collodion, applied over slight wounds by means of a bit of gauze or antiseptic cotton, where it is desirable to keep up the antiseptic treatment, forms a very neat dressing, the benzoinated collodion being a little more flexible. Prepara- fhe Operating room should be thoroughly cleaned, operating and, if possible, disinfected. It should contain, in addition to the operating and instrument tables, the following : Irrigator and glass irrigating nozles. Extra blankets and mackintosh. Hot and cold solutions. Boiling water, if possible. Extra night clothes. glycerin. Ben- zoinated collodion room. ANTISEPTICS AND ANTISEPTIC SURGERY. 29 Basins, large and small. Bucket. Bandages, adhesive plaster. Oil, vaselin, and catheters. Plenty of sterilized towels and small sheets. 50 Ns: Fig, 2.— Operating Pad. Fig. 3.— Irrigating Stand. Small sand-bags, covered with mackintosh, to use in supporting an arm or a leg. 30 SURGICAL NURSING. Operating table. Duties of the nurse. Syringe, oil-silk, scissors. Lint, absorbent cotton, pins, safety-pins. Drainage-tube, ligatures, sponges. Brandy, ammonia, hypodermic syringe, strychnin, digitalis. The temperature of the room should be from 6S° to 70° F. If the operating table be not supplied with a cushion, a folded blanket should be laid lengthwise upon it. It should -also have one firm pillow, protected with a mackintosh pillow slip. At the time of operation the cushion and pillow should be covered with a sterile sheet and pillow slip. A dressing rubber or operating pad is then arranged in such a manner as to protect the patient, and also to drain the water used in irriga- tion into a waste pan or bucket. Bandages, splints, and dressings should be conveniently at hand, and ready to apply the moment the surgeon requires them. It is more convenient to sterilize the towels and sheets in packages containing about half a dozen each. The aprons or operating gowns for the surgeons and nurses should also be sterilized in packages and plainly marked. The basins, pans, and containers for solutions or sterile water should be thoroughly scrubbed and disin- fected with bichlorid solution i : 1000 just before they are to be used. The duties of a nurse in an operating room vary according to circumstances and the requirements of the surgeon. She may be called upon to hand the ANTISEPTICS AND ANTISEPTIC SURGERY. 3 1 instruments., and for this reason should know all those in ordinary use, and where to find them ; again, she may be obliged to administer the anesthetic, either chloroform or ether ; or she may simply be required to attend to the sponges or ligatures. In handing instru- ments or sponges use a good firm touch, as very often the surgeon simply puts his hand out for the article desired, so it is necessary for him to feel it. Always try a ligature before giving it to the surgeon. After the hands have once been thoroughly prepared, first by scrubbing with soap and a stiff nail brush, giv- ing special attention to the finger nails, and then hold- ing the entire arm and forearm in bichlorid solution I : 1000 for several minutes, she should touch nothing which is not sterile. If gauze sponges be used, they should be sterilized in packages of a dozen each, and held in a sterile towel. When the sea sponges are used, it is necessary to have two basins; one containing cold sterile water, for washing out the blood, and the other warm solution or sterile water, from which the sponges are to be handed. Great care must be taken to have them squeezed as dry as possible, otherwise the wound becomes filled with water. The sponges should always be counted, especially in all abdominal work. If a sponge falls, never pick it up^ but, if necessary, supply a fresh one from the reserve stock. Whatever her duties may be, the nurse must watch attentively, and be ready to do anything which may be required. 32 SURGICAL NURSING. Before the dressing is applied, the soiled towels and sheets should be deftly withdrawn and their places sup- plied with fresh ones. It is a good plan to have no more about than is absolutely necessary, so as to give the surgeon plenty of room. An extra nurse should always be present to attend the patient after his removal from the operating table, never leaving him alone until he has entirely recovered from the anesthetic. There is always more or less danger attending even a slight operation, and every one connected with it should be extremely careful to observe all the rules of asepsis. Whenever it is possible, the patient should receive his initial preparation the day before the operation is to be performed ; this is especially desirable with children, who are apt to become more or less nervous during the proceeding. When this can not be done, prepare the patient as early in the day as circumstances will permit. Usually a purgative is given the evening previous, fol- lowed by a simple enema in the morning; this should be given as early as possible, in order to allow the bowels sufficient time to be thoroughly moved. No matter how careful and cleanly the person may be, there is always more or less excretion from the skin. In some persons the secretion from the cheesy or fat glands is far greater than in others ; or the mouths of these glands may be larger. Unless there be good reason to the contrary, the patient should have a full tub bath, or at least a good sponge bath. After the skin has been carefully washed, the region to ANTISEPTICS AND ANTISEPTIC SURGERY. 33 be operated upon should be thoroughly scrubbed with soap and a small brush, then carefully shaved, and again scrubbed with green or Castile soap. This should be followed by the use of turpentine, alcohol, ether, and bichlorid solution i : looo. A dressing wet with bichlorid solution i : 2000 is then applied. The same preparation is gone through with the morning of the operation. Some surgeons prefer to have the green soap applied Green soap as a poultice. The operating field is then smeared ^°" rather thickly with green soap, covered with several layers of gauze, and allowed to remain for fifteen or twenty minutes. The patient should be watched care- fully and the soap instantly removed if he complains of any irritation. The strength of the soap varies, and the skin in some cases is very sensitive and easily blistered by the soap. Should this occur, dust the skin with some aseptic powder. Green soap should never be applied to the scrotum or peritoneum in the form of a poultice ; the parts should simply be washed with the soap. In preparing a patient for abdominal section, special attention should be given the navel, which is usually packed with iodoform or other powder. Before beginning the preparation of a patient, the nurse should be sure of having all the necessary articles at the bedside, so that the work may proceed without interruption. In a hospital it is very convenient to keep a tray for this purpose containing the following : Green and Castile soap. Sharp razor, nail brush. 34 SURGICAL NURSING. Alcohol, turpentine, ether. Bichlorid solution, oiled paper. Sterile gauze, absorbent cotton. Bandages, scissors, pins. The whole tray should be kept covered with a sterile towel, and be always ready for use. Diet If the patient is to take an anesthetic, no food should of patient. , . _ _ . . , be given for from four to six hours previous to the operation, and then only milk or some very light article of diet. The patient should be clad in but one garment, opening in the back ; the neckband loosened ; the legs covered with long, loose, flannel stockings, reaching to the thigh. The clothing should be arranged for the convenience of the operator, and protected as far as possible from the discharge or hemorrhage by the arrangement of the dressing rubber or operating pad. When everything is in readiness, the patient should be placed upon the table, in a position convenient to the operator, and covered with a sterile sheet; another smaller sheet is thrown crosswise over the chest. The dressing rubber or pad is then arranged, and covered with a sterile sheet or towels ; the operating field is also protected by sterile towels. In abdominal work the entire abdomen is sometimes covered with several thick- nesses of sterile gauze, having a slit in the center through which the operator works. At the time of operation the nurse should be freshly clad in a clean washable gown, and should be careful to make her hands and forearms thoroughly aseptic by ANTISEPTICS AND ANTISEPTIC SURGERY. 35 scrubbing them with soap and a nail brush, giving special attention to the nails, and holding them for several minutes in bichlorid solution i : looo. A sterile apron entirely covering the gown is then put on. After being prepared, the nurse should not touch any- thing which is not sterile. If it be necessary for her to do so, she should again prepare her hands before going near the patient or handling anything pertaining to the dressings. Some operators prefer to have a constant, gentle stream irrigation, play over the operating field, and when this is done the solution should be warm, as it is dangerous to deluge a large surface or a deep cavity with a cold solution, on account of its depressing influence. The instruments, having been previously chosen by instru- the surgeon and sterilized, should be placed in the trays and entirely covered either with three per cent, solution carbolic acid or hot distilled water. Many surgeons prefer the latter, as it is less irritating to the hands. It is always best to have an extra tray with hot water, in which the soiled instruments may be rinsed before being placed among the others. As soon as the surgeon begins to use the instruments Sponges, the nurse should be ready to hand a warm, dry sponge. It is more convenient to have several in the hand at once, held in an antiseptic towel ; thus a fresh one can be handed at the same time the soiled one is removed. Ligatures will next be needed. These may be of Ligatures, catgut or Chinese silk, and should be cut about eighteen inches (i8 in.) long. Always have two ready to hand, 36 SURGICAL NURSING. as ihe first one may break. Always test it before hand- ing it to the surgeon. With most operators a small ligature is preferred, as the smaller the ligature, the smaller the knot. In tying, the vessel undergoes a process of healing; the ligature comes to an end, a clot forms, and the vessel becomes a fibrous cord. Drainage- As it seems impossible to prevent germs from entering ^" ^' a wound, they must be gotten rid of in some way or other. This is accomplished by the use of drainage- tubes. These may be made of perforated rubber, which comes in three different sizes, or of glass. The latter are generally used in abdominal cases, and can be ob- tained in different sizes, either bent or straight. Sometimes drainage is provided for by stitching a few strands of catgut or horsehair into the wound. This is usually done in scalp wounds. Where the rubber tubing is used, the ends are secured by a safety-pin, previously dipped in an antiseptic solution. Packing. Gauzc for packing, either plain or medicated, is cut in strips of the desired width, and carried down to the bottom of the wound, laid fold upon fold. It should be sterilized and kept in a large-sized test-tube, the opening being closed with sterile cotton ; or it may be wound upon glass spools and kept in a closely sealed jar. Sutures. When all is ready, the edges of the wound are brought together by means of sutures. These may be of silver wire, catgut, silk, or silkworm-gut. Ascertain, if pos- sible, which is to be used, so that the needles may be ANTISEPTICS AND ANTISEPTIC SURGERY. 37 threaded and ready to hand. Always give about three- quarters of a yard in length. After the wound has been washed, stitched, and the Protective edges neatly approximated, the line of suture is usually ing. dusted with some of the antiseptic powders, iodoform, aristol, or boric acid, and protectives applied, followed by the dressing, which usually consists of sterilized or bichlorid gauze. The dressing should be made suffi- ciently large to extend from two to four inches beyond the wound in every direction, and should consist of from sixteen to twenty layers, separated into a deep and a superficial dressing; the former about three inches smaller than the latter. Some surgeons prefer to use a rubber film between the last layers of gauze in the superficial dressing when it is desired to keep the dressing moist. If you have no film, parchment or waxed paper may be used in its place, always being careful to dip it in solution before inserting it between the gauze. The bandage may be either of gauze or the ordinary Bandage, muslin roller, as the case may demand. The gauze bandage applies itself more readily to the part. Some- times in a stump operation the dressing is confined by an adhesive strap. The Scultetus bandage is used in abdominal cases, and is also very convenient in chest operations. CHAPTER IV. ANTISEPTIC DRESSINGS. Preparation of Gauze — Bichlorid — Borated — Plain — Iodoform — Evaporating Dressings — Sponges — Liga- tures AND Sutures — Protective — Instruments. Keeping before the mind the aim of antiseptic sur- gery, which is to prevent putrefaction, it will readily be seen that it is not sufficient to render the wound thor- oughly aseptic at the time of operation or injury, but these precautions must be kept up so long as the wound requires a dressing ; hence, all the articles used must be specially prepared. Gauze Jn order to prevent the air from striking the wound, of various '^ c » kinds. and also to catch any discharge coming from the same, dressings of gauze are generally used. This is simply cheese-cloth which has been previously prepared by boiling for one hour in water sufficient to cover it, to which has been added two pounds of washing soda or strong lye. It is then wrung out, rinsed, and placed in bichlorid solution i : 2000 for twelve hours ; after which it is again wrung out, folded into suitable length and width, rolled while still moist, and securely wrapped in oiled paper. Borated. Boratcd gauze is prepared in the same manner, 38 ANTISEPTIC DRESSINGS. 39 except that a solution of boric acid is used in place of bichlorid. Plain sterilized gauze is often used, especially in ab- Plain. dominal work. Manufacturers usually fold the gauze in one-yard lengths. Iodoform and iodoformed gauze are two different iodoform *^ and lodo- things. The latter is made by sprinkling the materiaUormed. thoroughly with powdered iodoform, while in the former the iodoform is rubbed into the meshes. This may be done by wringing the gauze out of alcohol and then rubbing the iodoform thoroughly into its texture ; but a far better way is to prepare a solution of iodo- form, alcohol, and glycerin, first breaking up the iodo- form with a little distilled water; dip the gauze in this solution and then rub it thoroughly into the meshes. It will be found more convenient to cut the gauze into five-yard lengths, folding it lengthwise, three times, which will make it about 4^ inches in width ; this can be easily managed. Wring it as dry as possible, and either fold or roll it, keeping it in a glass jar. In pre- paring iodoform gauze, it is best to use plain sterilized gauze; for if bichlorid gauze be used, after keeping it for any length of time the red iodid of mercury is precipitated. In case of an emergency, where an antiseptic dress- Emergency , 1 -1111 dressing. ing is required and no gauze is at hand, absorbent cot- ton may be used, first baking it for a few minutes in an oven ; then wet it with bichlorid solution, then dry, and keep in cheese-cloth bags. Alcohol or evaporating dressings are frequently used 40 SURGICAL NURSING. Alcohol or evaporat- ing dress- ing. Sponges. Gauze. Sea sponges. Mode of preparing sponges. where there is a tendency toward inflammation. In this case lint is generally preferred, wrung out of equal parts of alcohol and distilled water; or, if a more soothing dressing is required, equal parts of alcohol, distilled water, and witch-hazel. The dressings are kept moist by means of waxed paper, and are changed several times during the day, and are very grateful to the patient. In all operations sponges will be used. These may be either of gauze or the regular sea sponge. If gauze be preferred, a better way is to take oblong pieces of the material, and fold them to the required size, turning all the edges on the inside, slipping the last edge into the opposite fold (as you would slip the flap of an envelop into the envelop), thus holding it in place. A little experience in doing this will enable you to make a very neat sponge of sufficient thickness to answer all purposes. A simpler way is to fold the gauze the desired width and cut it into squares, but in this way the layers of gauze separate. Gauze sponges are now used entirely by many surgeons. They can be readily sterilized and are inexpensive, one yard making from twelve to fifteen, according to the size. Of the sea sponge, the fine surgeon's sponge, coming in strings of about fifty, is to be preferred,, and may be prepared in any of the following ways : All sponges have a certain amount of sand in them, which must be removed by beating them between coarse material of any kind (a canvas bag is best) with a wooden implement in order to avoid cutting the sponge. ANTISEPTIC DRESSINGS. . 41 After the sand has been removed, the sponge should be rinsed and placed in diluted muriatic acid for fifteen minutes ; then washed in cold water, then in warm water with green soap; then rinsed thoroughly, and placed in five per cent, or i : 20 carbolic solution. Another mode of treatment is first to beat the sponges, then soak them in warm water twenty-four hours, then in Condy's fluid f^j, to gall, j of water for another twenty-four hours, after which they should be washed thoroughly in warm water and placed in sulphuret of sodium f^j, hydrochloric acid f^j, and water gall, j, for one minute; they should then be removed, washed thoroughly, and placed in five per cent, carbolic solu- tion. A simpler and, in my experience, a far better method than either of the preceding is to beat the sponges well in a canvas bag to remove sand ; then immerse them in a solution of muriatic acid, f^j to Oj of distilled water for three hours to remove remainder of sand ; then keep for eight hours in hot running water, then immersed in bichlorid solution i : tooo for ten hours, then rinse and preserve in five per cent, carbolic solution. To bleach sponges, soak for one hour in five per cent. Bleaching. solution of permanganate of potassium ; afterward wash them in pure water, then in a saturated solution of oxalic acid ; rinse thoroughly and keep in a carbolic solution. Ligatures are composed of animal tissue. The cat- i-'ga*"''^s gut, ranging in size from o to 4, is generally used. It sutures. may be chromicized or non-chromicized ; the latter is 4 42 . SURGICAL NURSING. called "Kosher Gut." It is flexible and thoroughly- antiseptic when properly prepared, and does not last longer than the tissues allow, which is from one to five days. To prepare the gut, first wash it in alcohol, then place it in the oil of juniper berry for twenty-four hours, after which keep it in alcohol ready for use. When it is desired to have the gut last longer, as in sutures and in the ligation of large arteries, place the non-chromicized gut first in alcohol, then in five per cent, carbolic solu- tion to which has been added thirty grains of bichromate of potassium, where it should be kept forty-eight hours or longer, as the surgeon may direct, after which it is preserved in alcohol. This gut will last from fourteen to twenty-one days. Another method, formulated by the late Prof. S. W. Gross, M.D., of Jefferson College, is as follows : " Raw catgut should be placed for half an hour in one per cent, alcoholic solution of corrosive sublimate, to which has been added five per cent, of tartaric acid. It should then be placed on a cloth wrung out of i : looo watery sublimate solution until it is dry. It is then trans- ferred to, and kept permanently in, oil of juniper berry, but should not be used prior to the expiration of ten days. When it is desired to employ the gut, it is cut into suitable lengths and wiped with a towel which has been soaked in a i : looo watery solution of cor- rosive sublimate. It is then placed for half an hour in a I : looo watery solution of sublimate to which has been added one-fifth its weight of alcohol, the latter agent preventing the gut from untwisting and preserving ANTISEPTIC DRESSINGS. 43 its rotundity. Prepared in this way, catgut is absolutely aseptic." * Silk ligatures and sutures are also used, and may be had in surgeon's silk, twisted Chinese, or the iron dyed silk ; the latter is not so well suited for deep ligations, the majority of surgeons preferring the twisted Chinese. Whichever variety is chosen, it must be first boiled in distilled water for one hour, then placed in five per cent, carbolic solution for twenty-four hours, after which it should be kept in alcohol ready for use. Another way, somewhat quicker, is to boil for one hour in five per cent, carbolic solution, then keep in alcohol. It is more con- venient to have it wound on glass spools. Silk- worm gut has simply to be thrown in carbolic Siik-worm solution a few minutes before using, or kept in alcohol. ^"^" The protective agent consists of oiled silk which has Protective been subjected to a coating of copal varnish and then^^^" ' thoroughly brushed over with a mixture of dextrin to which has been added two parts of powdered starch and sixteen parts of five per cent, carbolic solution. It is used to prevent the air from entering the wound, and also to prevent the dressing from becoming adherent. Drainage-tubes, either of rubber or glass, should be Drainage- kept in five per cent, carbolic solution. ^" ^^' All instruments should be thoroughly sterilized before instru- ments. * A more recent method is to sterilize the gut in absolute alcohol , under pressure. This is done for three consecutive days, sterilizing the gut one hour each day. 44 SURGICAL NURSING. and after using, and should never be placed in bichlorid solution, as it dulls the edge and discolors the steel. In preparing the various articles, great care must be taken to have the hands thoroughly aseptic, as well as all Fig. 4.— Glass Drainage-tube. Fu ■Rubber Drainage-tube. the utensils used; for wherever antiseptic treatment is desired, it must be carefully carried out, even to the most minute detail ; and as this is largely left to the nurse, who is frequently held responsible if any mishap befall the patient, she can scarcely be too careful. CHAPTER V. GYNECOLOGIC NURSING. Definition — Preparation for Examination — Position of Patient — Instruments Used — Catheter — Care of Pa- tient AFTER Operation. Gynecology, in medical language, comprehends the Definition. study and treatment of diseases peculiar to women. It is often necessary to examine the patient without Prepara- removing the clothing, which should be putentirely out amination. of the way and all constricting bands loosened. Whenever it is possible, a douche and simple enema should be given shortly before a vaginal or rectal ex- amination ; at least, see that the parts are clean. When the patient has been placed in the desired position, place a dressing rubber covered with a sterile towel beneath the buttocks; when the surgeon is ready, the nurse should arrange the covering with as little exposure as possible. A basin containing" warm water, soap, and a nail- brush should be in readiness for the surgeon's hands. He will also require sterile sweet-oil for lubricating the instruments, carbolized cosmoline, absorbent cotton, towels, and Castile or green soap for the finger-nails. Green soap is preferred, because with it the odor of the secretions can be easily removed. 45 46 SURGICAL NURSING. instru- The instruments — generally a Sims' speculum, uterine ments used . in examina- sound, appHcator, and several cotton-holders — should tion. ^^ be freshly sterilized and placed in warm, sterile water. If an application is to be made, tincture of iodine or nitrate of silver solution should be in readiness. Position In all gynecologic work it becomes necessary to pa len . ^i^^^ ^^^ patient in one of several positions, in order that the work may be quickly and easily accomplished. Dorsal In the dorsal position, which is the one most fre- position. quently adopted, the patient lies upon her back, her head resting upon a pillow, the legs are flexed upon the thighs, and the thighs upon the abdomen; the feet should rest in stirrups, or the feet and knees may be supported by an assistant on either side ; the body of the patient is brought down to the end of the table. Semiprone In the scmiprone or Sims* position the patient lies or Sims' ^ . . ^ ^ position, upon her left side, her hips at the left-hand corner of the table. The knees are well drawn up upon the chest, the right knee a little higher than the left, and both knees should be kept well flexed. The left arm is drawn behind the patient's body. Genupec- In the ^euupectoral or knee-chest position the patient toral or o ^ knee-chest is placed upou the table, with the weight of the body resting upon the knees, which are separated, the side of the face, and the front of the chest; the arms are supported upon the sides of the table. Trendeien- The Treudekjiburg position is now extensively used poskion. in all abdominal operations, and is maintained by plac- ing the patient upon her back, with the knees greatly flexed, and the whole body and limbs so elevated as to GYNECOLOGIC NURSING. 47 form a steep incline from the shoulders to the knees ; the back is slightly arched. When this position is re- quired, the Trendelenburg, or some similar operating table with which it is possible to secure this position, is used. There are various kinds of specula, of which Goodeirs ^ ' speculum Fig. 6. — Goodell's Speculum. Fig. 7.— Fergusson's. Goodell's bivalve is now considered the best. In handing the instrument always be sure that the set screws are set far away from the handle, to secure the proper adjustment of the blades. Fergusson's speculum is an old-fashioned instrument, Fergus- 48 SURGICAL NURSING. now seldom used. It is usually made of hard rubber, but is also made of glass. Fig. 8.— Sims' Fig. 9.— Robb's Modification. Sims'. Sims' speculum has two blades upon one handle, one larger than the other. Cusco's. Cusco's speculum is also a bivalve, one side being GYNECOLOGIC NURSING. 49 roughened into a collar. It is limited in its utility, and is now seldom used. The speculum being inserted, speculum forceps will Specuiui forceps. Fig. 10. — Cusco's. Fig. II.— Speculum Forceps. next be used. These are long, slender instruments, used for removing tampons, or for cleansing purposes. Care must be taken to catch the cotton lightly, but firmly, in order to avoid forcing the springs apart. 50 SURGICAL NURSING. Tenacii- Uterine hooks, or tenacula, are often necessary. Sound. The uterine sound is simply a long-handled sound, with a shoulder two inches in length, made of flexible copper-plated wire. It is sometimes used without the speculum. Applicator. The applicator consists of a piece of aluminum wire Fig. 12. — Tknactla. mounted in a long handle, roughened at the end, to admit of the cotton becoming firmly attached. In wrapping cotton upon the instrument, care must be taken to do it very neatly, making it about as thick as the end of the probe; and be sure that the same is ^L. Fig. 13.— Sound. securely held upon the instrument, so that there is no danger of its being left in the cavity. The surgeon will indicate the solution to be used, and will prefer to apply the same himself. Tincture of iodin, pure carbolic acid, nitrate of silver, and, sometimes, tannic acid cut with glycerin, are the solutions generally used. GYNECOLOGIC NURSING. 51 Cervix forceps are long-handled toothed forceps, with Cervix a small hook, which allows the tissues to be firmly held, and should always be handled carefully. Fig. 14. — VoLSELLA Forceps. Volsella forceps are long-handled instruments, used Voiseiia forceps. in lacerated cervix. Curets consist of a hoop or spoon, with a long handle. Curets. They are of various sizes, both blunt and sharp. Fig. 15. — Sh.\rp Curet. Fig. 16. — Blunt Curet. Cervix scissors are long-handled curved scissors, and Cervix ° ' scissors should never be used for any other purpose than that for which they are designed. 52 SURGICAL NURSING. There are also double-curved, angular, and straight scissors. The latter are known as *' Kuechenmeister's," having a point at the end, and are preferred by some surgeons. Tampons. In making applications to the mouth of the vagina. Fig. iS.— Kuechenmeister's Cervix Scissors. tampons made of cotton, wool, lint, and, in case of emergency, even old cloth, are used. They must be neither too large nor too small, but just right, and may be medicated as the surgeon directs. A very convenient form for use in private practice is GYNECOLOGIC NURSING. 53 the gelatin capsule, filled with Globe antiseptic wool. Before inserting the latter it is necessary to moisten it a little. Sponge tents are made of a variety of substances, Sponge and are used to dilate the os and cervix uteri. Vaginal suppositories do not differ from rectal sup- Supposi- . . ^ , , , tories. positories, except that they are larger. The use of the catheter, when once thoroughly un- Catheter. derstood, is not a difficult matter, and should occasion very little discomfort to the patient. Every nurse should be able to catheterize by touch. Fig. 19.— Sponge Tents. In order to do this, the index finger of the left hand, well-oiled, is inserted into the vagina and brought for- ward in the niedian line, against its anterior wall. The urethra will then be separated by but a thin partition. The catheter, held in the right hand, is then slipped forward over the finger until it reaches the situation of the urethral orifice, when it will, with a little practice, pass readily into the bladder. The catheter should be inserted for the distance of i^ inches. When the catheter is withdrawn, care should be taken to close the outer orifice with the index finger, so as to 54 SURGICAL NURSING. prevent the escape of the urine yet remaining in the catheter, and so soiling the clothing or interfering with the process of healing after an operation relating to any neighboring parts. This precaution is especially necessary after the operation for repairing a lacerated perineum, as the Fig. 20.— Silver-plated Catheter. dripping of urine upon the parts may excite inflamma- tion and suppuration, and thus render all the surgeon's work worthless. The French or olive-pointed catheter is firmer than the Nelaton or soft rubber, and is preferred by some surgeons. The Nelaton, a soft, flexible catheter, is perfectly ^■eWT-Z. ttSQWS Fig. 21.— Glass Catheter. safe, and gives very little discomfort to the patient. Nos. 17 to 20 are the sizes generally used. Of the English catheters, No. 8 is to be preferred ; before insertion it should be slightly warmed in the hand, or by dipping in warm water. Boiling or even very hot GYNECOLOGIC NURSING. 55 water should never be used in cleansing the soft cathe- ters. Catheters are also made of glass and of silver, and in the hands of a skilful nurse are highly recom- mended. The bladder, situated behind the pubic bone, is a highly sensitive and vital organ, and is emptied by the urethra, which is a tube i^ inches in length, extending from the external orifice in the vaginal wall, upward and backward, nearly in line with the same. All instruments used in connection with these organs should be warm, scrupulously clean, and freshly steril- FiG. 22.— Double-current Catheter. ized. Each time after using the catheter it should be carefully sterilized, and well syringed either with bichlorid i : 8000 or carbolic solution i : 40, special attention being paid to the eye of the instrument. When not in use, they should be kept in a glass catheter bottle or in a sterile towel. After all gynecologic operations the patient should Care of pa- be kept perfectly quiet. She may lie in any position in operation, which she is placed, but should not be allowed to move herself. An easy way to change the position from one side to the other is to gently lift the mattress at one 56 SURGICAL NURSING. side, when she will find her position changed without having been occasioned the least discomfort. After all operations of this nature patients are more or less subject to ''hysteria," which must be dealt with as in other cases. They will often fancy they are going to have peritonitis, if there be any pain in the abdomen, or perhaps because one of their parents or friends died from this disease. Such fancies need occa- sion no alarm, and it becomes the duty and privilege of the nurse, as at all other times, to endeavor to encour- age and reassure the patient, leading her mind back to brighter and happier thoughts. CHAPTER VI. GYNECOLOGIC NURSING (Concluded). Injections — Temperature — Time of Giving— Quantity — Position and Care of Patient— Medicated Substances Used — Table — Venereal Disease — Abrasion of the Skin, In all gynecologic work injections will form a large injections part of the treatment. The simplest form of injection is hot water, which often forms the sole treatment. Before giving an injection of any kind always ascertain the exact temperature desired, testing the same by the use of a thermometer. A warm injection should be given at about the tem- Tempera- perature of the body, or a little higher, say ioo° to ioi° F. It may be used at a temperature of no°, but never higher, without specific directions from the surgeon. Water, while running through the tube, becomes cooled, and should always be maintained at the indi- cated temperature. All injections are best given upon going to bed, unless ordered twice a day. In cases of inflammation the condition rapidly improves under this treatment. The usual quantity given is about one gallon, prefer- Quantity 5 ,57 syringe. 58 SURGICAL NURSING. ably by the use of the fountain syringe, hung just high enough to insure a continuous flow. The Davidson syringe is also used, but with it the same evenness of flow can not be obtained. The nozle of the syringe is of importance; the regular large size vaginal nozle, having perforations at the side, is to be preferred. Position The position of the patient is of great importance. pa len . ^y^^gn taking an injection herself, the patient is apt to place herself in a sitting posture, rendering the treatment practically useless, as it is impossible to reach the entire surface in this position. The better way is to place the patient upon her back, with hips slightly elevated. In a normal condition the canals of the body are in contact with each other, so if you wish to medicate the entire surface, this position must be adopted. Care of Beforc giving an injection of any kind a mackintosh patient. a a j or operating pad should be placed beneath the patient to protect the bed and clothing. Keep the patient well covered, especially while giving a hot injection, as exposure to cold at such a time might undo all the good for which the treatment was designed. The water should be permitted to run slowly and evenly. Substances The substances used for medicated injections may be me^dicated divided into two classes : Antiseptics and astrin- injections. ^^^^^^ The antiseptics are bichlorid of ??iercury, formal, carbolized lotions, and boric acid. The astringents are divided into mineral, embracing sulphate of zinc, ace- GYNECOLOGIC NURSING. 59 tate of lead i and alum; and into vegetable ^ embracing tannin and white oak bark. Permanganate of potassium is a deodorizer, but is not highly recommended on account of its staining prop- erties. Except when using bichlorid, formal, or carbolic solution, it is best to make the desired solution at the time of using. The surgeon will in all cases give directions as to the strength of the solution to be used. Bichlorid is usu- ally preferred in solution i : 8000. It has been found from experience that even used in strengths of i : 1200 or I : 2000 it causes some pain. Formal is used in from two to five per cent, solution. Carbolic acid is seldom used ; when it is employed, the strength of solution is gener- ally I : 100. The following will be found a convenient table for making the several solutions : One heaping teaspoonful * of — Alum, 2 drams Sulphate of zinc, 2 drams Acetate of lead, I j^ drams Tannin, J^ dram Crystallized boric acid, 100 grs. ' Pulv. boric acid, about 90 grs. The crystallized boric acid is best for general use, the pulverized being more slow to dissolve. The crystals dissolve more easily in warm water. With the * Lecture delivered by Dr. Neilson. 6o SURGICAL NURSING, exception of tannin, dissolve the above in one pint of water, which will make the solution of proper strength. With tannin, use one tablespoonful to the pint. Nitrate of silver is also objectionable on account of its staining properties, but is too valuable a remedy to be discarded, especially in some cases of gonorrhea. Of course, a weak solution is used, gr. j to f gvj of water, making a solution of i : 2500. It becomes decomposed by the action of light, and should be kept in a dark bottle, away from the direct rays of the sun. If the solution be spilled, cover the spot with common salt. Venereal In gynccologic work both the surgeon and nurse often meet with cases of unsuspected syphilis and other venereal diseases, which, while extremely loath- some, are usually interesting to the surgeon, as they readily answer to treatment. The virus of syphilis is highly contagious. Any abrasion of the skin may carry the poison, and great care must therefore be taken to avoid contact with the secretions, thoroughly protecting with collodion * any scratches or cuts you may have upon your own hands before going to the patient. If you should be so unfor- tunate as to become inoculated, soak the hands at once in bichlorid, apply nitrate of silver to the spot, and consult the surgeon. Wherever it is possible, instruments used in these cases should not be used upon other patients. If this is impossible, they must be rendered thoroughly aseptic before they are again used. GYNECOLOGIC NURSING. 6l The same care should be exercised in regard to any linen or articles of clothing used about the patient. Where there are syphilitic outbreaks about the mouth, special dishes should be reserved for the use of the patient. Gonorrhea consists of a purulent, contagious dis- charge from the urethra or vagina. Inoculation is easily effected by contact with the mucous membrane ; thus, if after handling a patient suffering from this dis- ease you should touch your eye or nose, those organs would easily become affected. The same care is necessary in regard to all instru- ments and utensils used as in syphilitic cases. Children of the poorer class, such as we meet with in hospitals, often suffer from inherited syphilis or tuber- culosis. Patients suffering from excoriation or abrasion of the Abrasion skin may be relieved by dusting the part with pulver- °^ ^^^ ^'""' ized boric acid and oxid of zinc in equal proportion. CHAPTER VII. HEMORRHAGE. Circulation — Blood — Situation of Some of the Arteries — Definition — General Symptoms — Kinds — Ways of Ar- resting— Instruments Used. Circuia- In Order to understand the cause of hemorrhage, it is necessary to understand something of the circulation of the blood, which has been compared to a central pump with a distributing and collecting system — the heart representing the pump, the arteries and veins the dis- tributing and collecting system. The heart is a cone-shaped organ, situated nearly in the middle of the chest, with its apex, or small end, pointing downward, forward, and to the left, and is anatomically divided into two organs. The large veins from the head and lower extremities empty, by means of the superior and inferior venae cavae, into a right chamber of the heart, called the right auricle, from its resemblance to an ear ; from the right auricle the blood passes through the auriculo-ventricular orifice, guarded by the tricuspid valve, into the right ventricle, and then passes through the pulmonary artery, to the lungs, where it is purified, and returns by means of the four pulmonary veins to the left auricle, passing 62 HEMORRHAGE. 63 through the auriculo-ventricular orifice, guarded by the mitral valve, into the left ventricle; thence through the aortic orifice to the aorta, which distributes it through the body by means of smaller branches. These small ar- teries finally terminate in the capillaries, which, after dividing and subdividing, supply the different organs and tissues with blood. The capillaries unite to form the veins, which are all finally combined in the superior and inferior venae cavse. The left heart supplies ar- terial blood, which has received oxygen as it passed through the lungs. JVhen the blood comes from the system, it carries with it carbon dioxid gas, and is purple or bluish in color. As it passes through the lungs it gives off the carbon dioxid and takes on oxygen, and becomes red in color. Blood is composed of both liquid and solid elements, composi- The liquid is known as liquor sanguinis, or plasma, and biood. consists of the nutritive principles of the food. The solid elements are the corpuscles, of which there are two kinds, red and white. The red corpuscles, as seen in the human body, are small circular bodies, flattened into thin plates or discs, and are the oxygen carriers. The white corpuscles, more globular in form, are trans- formed into red corpuscles, and are otherwise concerned in the nutritive processes of the body. An excess of white corpuscles in the blood produces a disease called leukocythemia. Life depends upon a thorough carrying out of all the functions of the body ; hence, if the blood becomes less 64 SURGICAL NURSING. in quantity, as the result of hemorrhage, or thinner and paler, from a lack of red corpuscles, as in anemia, a loss of strength is felt. In health the breaking- down of the blood-corpuscles and loss of blood can be restored. In order to control hemorrhages, a knowledge of the situa- tion and relation of the principal arteries is necessary. Temporal In arresting hemorrhage from the temporal artery, pressure should be made in front of the ear. Situation of The Subclavian artery extends from its origin to artery.^'^" the outer border of the first rib. To arrest hemorrhage from this artery the shoulder should be depressed ; grasping the side of the neck, press with the thumb or the handle of a long key in the hollow behind the clavicle, downward against the rib. If for any reason the shoulder can not be syfficiently depressed, pressure may be made from before backward. Axillary. The axillary artery runs from the outer border of the first rib to the axilla. Compression of this artery is sometimes required, and can only be effectually ac- complished in the lower part of its course by pressing upon it from within outward, against the humerus, and by the use of a firm compress in the axilla. Brachial. The brachial artery passes obliquely down the inner side of the arm to the middle of the bend of the elbow. Radial. The radial artery passes along the outer side of the forearm, guarded by the muscles and tendons; it is easily felt at the wrist. To control hemorrhage, com- pression may be made at almost any point in the course of the brachial artery. If pressure be applied at the HEMORRHAGE. 65 upper part of the artery, it should be from within out- ward ; and if on the lower part, from before backward, as the artery lies on the inner side of the humerus above, and in front of it below. The ulnar artery runs along the ulnar side of the ulnar. forearm, becoming near the wrist more deep-seated than the radial, and ends in the palm of the hand by forming the superficial palmar arch. Bleeding from the palmar arch is always serious ; pressure should be made at both sides of the wrist, and by a firm compress held in the palm. The femoral artery extends from the center ofpemorai. the groin, along the anterior and inner side of the thigh, to the junction of the middle with the lower third of the thigh, where it becomes the popliteal artery. It is a large vessel, easily found, hemorrhage from which is always serious. Pressure should be made im- mediately below Poupart's ligament. The vessel may also be compressed in the middle of the thigh, by placing a compress over the artery, be- neath the tourniquet, and directing the pressure from within outward so as to compress the vessel against the inner side of the shaft of the femur. At the ankle there are two vessels : the anterior Anterior and posterior tibial. The anterior tibial lies deep rior ubtal in front, between the first and second tendons. A line drawn from the inner side of the head of the fibula, midway between the two malleoli, will mark the course of this artery. The poste?'ior tibiae artery lies between the inner 66 SURGICAL NURSING. Definition. General symptoms. Kinds. malleolus and the heel, ascending the tibial side of the leg to the popliteus muscle. Hemorrhage from these vessels can be controlled by digital pressure or by com- press. A sudden rush of blood which empties the system constitutes hemorrhage, and is dangerous to life. The general symptoms of hemorrhage are pallor and an almost imperceptible pulse. As the hemorrhage continues, this pallor becomes extreme, rendering the skin almost like wax ; the lips become thin and blue ; nostrils pinched ; pulse small and rapid ; the respira- tion shallow ; the thirst extreme. Not only the mouth, but all the mucous membrane of the body becomes parched. The same symptoms prevail whether the hemorrhage be internal or external. The nature of the bleeding can be easily distinguished, as blood coming from an artery issues in jets or spurts, and is bright red ; while that from the veins, with the exception of the jugular and subclavian, gushes, or oozes in a more or less constant stream, and is darker in color. In old or asthmatic persons the arterial blood is slow to regain its color, and so is only distinguished by the character of the flow. In deep-seated wounds, where the artery is more or less covered, the bright-red blood may be seen flowing over the edge of the wound in a little stream, and so is easily distinguished by its color. In the old and feeble, and in very young persons, a hemorrhage is dangerous, not only on account of the quantity of blood lost, but also in the eff"ect upon the patient. HEMORRHAGE. 67 Syncope, or fainting, is nature's way of arresting Nature's Hemorrhage. After a certain amount of blood has been arresting ° hemor- lost, the vessels dilate and lower the pressure. In con- rhage. sequence the heart's action becomes depressed and sends less blood to the brain, and fainting or unconsciousness results. In this case keep the patient quiet, with the head low, avoiding stimulants ; this condition of syn- cope favors the formation of a ** blood-clot " in and around the artery. When reaction takes place, there is danger of a re- currence of the hemorrhage. Means should therefore be taken to effect a permanent arrest of the hemorrhage. Death resulting from hemorrhage is entirely painless. Nature does not always perform her part, in which case it becomes necessary to employ surgical means. If brought face to face with a wounded vessel of the arm or leg, for example, from the signs already given you could easily determine whether the bleeding were arte- rial or venous. If arterial, press the bleeding point with the finger or Digitai^^ thumb; it is better to use both, and so support the opposite surface. If there be time, of course disinfect the same ; but in case of emergency stop for nothing. If not very violent, do not thrust the finger directly into the wound, but above or below the point of bleed- ing, according as it is arterial or venous. In arterial hemorrhage from scalp wounds place the finger below, nearer the heart, and at a short distance from the wound. In venous hemorrhage from a superficial vein place 68 SURGICAL NURSING. the finger below, in case of the extremities, and above, in case of the head. Compress. A graduated compress placed above or below, as the case may require, secured by a bandage, may be used. Fig. 23.— Petit's Tourniquet. Spanish windlass. If it be at hand, first cover the wound with bichlorid gauze. If alone, and without proper conveniences, anything may be used. A handkerchief folded triangularly and tied in a loop, the knot over the vessel, pressure being applied by HEMORRHAGE. 69 means of a. stick by which the handkerchief can be twisted, forming what is called the *' Spanish windlass," is excellent. In amputations and other major operations the instru- . , , /- 1 1 1 1 r 1 • mentsused. great aim is to avoid loss of blood ; and for this pur- pose various instruments are employed by the surgeon. Petit' s tourniquet consists of a strap fastened to apetit's chain or key, which is held in position by a buckle. ou-mque . In using this instrument, a primary roller is first ap- plied, then the tourniquet, buckling the strap over the Fig. 24.— Esmarch's Rubber Bandage. roll of bandage. Before handing this tourniquet always be sure that the little pad beneath the buckle is in per- fect order. Esmarch's rubber bandage is applied in opera- Esmarch's tions upon the extremities to save loss of blood. Begin bandage. to bandage from the lower extremity of the limb, thus forcing the blood up above the point of operation, where the tourniquet or rubber tubing is applied, the latter being fastened by means of a hook and chain. 70 SURGICAL NURSING. It is usually necessary to have an assistant to hold the limb and bandage in position, especially in hip-joint and shoulder amputations. Hemorrhage in hip-joint Fig. 2s.— Esmarch's Tubinu. Fig. 26.— Esm.^rch's Hard Rubber Compress. amputations is difficult to control, on account of the size of the vessel. Forceps. Other instruments used are the heiJiostaiic forceps^ which catch the vessel firmly, and differ from the dressing HEMORRHAGE. 71 forceps by coming closely together at the points, being perfectly flat, and are usually in two pieces. Dressing forceps are hollowed out on the inner side. Fig. 27.— Liston's Self-closing Artery Forceps. Fig. 28.— Hemostatic Forceps. Fig. 29. — Tenaculum, Liston's self-closing artery forceps, once applied, Liston's keep in position, but are now seldom used. The tenaculum is a hook-like instrument, useful as Tenacu- lum, a retractor. 72 SURGICAL NURSING. Aneurysm needle. Acupres- sure pins. Harelip pins. Cautery, The aneurysm needle is a long, curved instrument, used to pass the ligature around the artery, made blunt to avoid injuring the vessel. Acupressure pins are spear-pointed pins which are passed through the tissues of a wound so as to com- press and close, by the middle portion of the needle or pin, the tube of the bleeding vessel. Harelip pins are often used in scalp wounds, and are secured by a suture of the same name. Any large- headed steel pin may be used for the same purpose. Still another way of arresting hemorrhage is by the Fig. 30.— Aneurysm Needle. use of the actual cautery, Dr. Paquelin's being the most convenient. As will be seen in the accompanying illustration, this instrument consists of a glass reservoir having a per- forated stopper connecting with rubber tubes, one on either side; to one of them is attached a platinum point, the other ending in two bulbs. When the instrument is to be used, fill the reservoir a little less than half full oi fresh benzene; attach the point, and heat it by holding it in the flame of an alcohol lamp until it shows a slight cherry-red heat ; then press the hand-bulb very gently and slowly, blow- ing very little gas into the point ; if the heat then HEMORRHAGE. 73 increases, the burner is lighted, and the bulb should gradually be pressed more frequently until the desired heat is obtained. If upon pressing the bulb the heat dies out instead of increasing, it is a sign that the platinum is not hot enough to light the gas. In this Fig. 31.— Paquelin's Cautery. case all pressure on the bulb should cease until the point begins to glow again with a slight red heat, when the bulb should be again pressed slowly until the burner is as hot as required. The point is then removed from the flame, and by pressure upon the bulb will retain its heat as long as needed. 6 74 SURGICAL NURSING. Heating the cautery to a white heat should be avoided ; for this high temperature, if kept up for some time, may melt the inside tube of the combustion chamber. The instrument should always be allowed to cool slowly in the open air, and it should be cleaned after each operation. The inside tube is cleaned by heating to a vivid red, and while in this incandescent state, separate the handle suddenly from the rubber tubing which connects it with the reservoir. When the outer tube has become cold, rub it with a damp piece of linen. CHAPTER VIII. HEMORRHAGE (Concluded). Constitutional Treatment — Position — Stimulants — Kinds OF Hemorrhage. The first step in the treatment of hemorrhage, after Constitu- the bleeding has been stopped, is to place the patient in treatment. a condition of absolute rest, both mental and physical ; noise and worries of every kind should not be allowed to disturb him. The loss of blood has lowered the temperature of the body, so external heat, by means of hot-water cans or bottles, must be applied, being careful that they are well protected, and not so hot that the patient runs the risk of being burned. Some surgeons suggest the use of a water bed filled with hot water when the temperature of the patient has been greatly reduced. The^position of the patient is also important; remove pogitj^,, the pillow, and elevate the foot of the bed, to allow a sufficient flow of blood to the brain, and so overcome faintness. Few surgeons advise the use of stimulants in large stimu- quantities at such a time, as they increase the action '^"*^" of the heart. Moreover, the stomach is incapable of absorbing much of anything. Ammonia is considered better to give than brandy. 7d 7^ SURGICAL NURSING. To allay Qiie of the most distressing symptoms is the excessive thirst, occasioned by the loss of fluids from the system. This is best allayed by giving sips of hot water, in preference to cold, bits of crushed ice, or injections of hot water. The hot water, being at a temperature a little above that of the body, is more readily ab- sorbed. In cases of extreme restlessness one-half grain opium suppositories are often given. Care As the patient becomes convalescent, great care should pa leii . ^^ takej^ that he does not become overfatigued or wor- ried in any way. Moderate exercise in the open air is good; and when the system recovers sufificient strength, some mineral tonic, such as iron, is usually given ; increase the diet, giving easily assimilated, nitrogenous food. Kinds of Epistaxls, bleeding from the nose, is often met rhage!" with ] in many persons the disease is periodic and has a beneficial effect upon the patient. It is usually caused by plethora, injury, vascular excitement, deter- mination of blood to the head, or by a want of tone in the blood-vessels, and is preceded by headache and giddiness, accompanied by flashes of light. Small doses of salts, taken daily, or any of the saline waters will generally afl"ord relief. This mode of treat- ment is sometimes spoken of as " bleeding the patient through the intestines." If, however, the hemorrhage amounts to more than dripping, it may become serious and require surgical attention. In any case, do not allow the patient to HEMORRHAGE. 77 hang his head down, for when the neck is flexed upon the chest, it prevents the return of blood to the heart and increases the congestion, thus increasing the flow of blood. Place the patient in a recumbent position, head thrown back and turned to one side, placing towels or a sponge near the nostrils to catch the discharge. An old and very simple treatment is to drop cold keys or pennies down the back ; or gently rub the temples, cheeks, nose, and nape of the neck with ice. In both cases the effect is the same, as cold applied to the sur- face of the body stimulates the nerves and causes the vessels to contract. Ice-cold astringent solutions of alum, gr. xx or gr. XXX to the ounce, or tannin, one dram to one ounce of water, are sometimes injected up the nostrils. Direct the patient to take long, full, deep breaths, which act by facilitating the return of blood to the heart, and so relieve congestion. In some cases, as in fracture of the nose, or where Plugging . posterior there is a tumor, extreme measures have to be em- nares. ployed, such as plugging the posterior nares. This is accomplished by the use of Bellocq's cannula, or a soft rubber catheter. The cannula, armed with a strong ligature, is gently passed up the nostrils until it can be seen protruding into the mouth when the ligature is seized and brought out of the mouth, and secured to a plug of lint or anti- septic gauze ; upon withdrawing the instrument, the plug is brought into position in the posterior nares. 78 SURGICAL NURSING. when the anterior nares is also plugged. The end of the ligature is allowed to protrude from the mouth to facilitate its removal. At best, this is harsh treatment, and the more hu- mane way is to find the point of bleeding and apply the cautery. Hemopty- Hemoptysls, or spitting of blood, is the most com- mon form of bleeding from disease. It may be moder- ate, considerable, or severe, and may occur once or be repeated a number of times. Patients suffering from consumption all display one characteristic — in repudiating the fact of severe illness, until a hemorrhage occurs, when they become wild with fear and excitement. As in all other case of hemor- rhage, it is of vital importance to impose absolute rest and quiet, keeping the patient in a recumbent or semi- recumbent position, propped up with pillows. Treatment If alone in such a case, place a teaspoonful of salt alone. upon the touguc, and direct the patient to swallow it, or give a little vinegar. Ergot may be given in doses of from thirty to sixty drops. Do not repeat if sixty drops be given. The better way is to give a small dose, say forty drops, and follow it in a short time by thirty drops. Cold applied to the surface of the body is also good. Bare the chest and allow the cold air to strike it ; in some cases, rub the chest with ice ; of course, care must be exercised that this treatment is not continued too long. In all cases hemorrhage is followed by more or less HEMORRHAGE. 79 exhaustion. Care should be taken in administering stimulants, aromatic spirits of ammonia being better than brandy. Hemorrhage from the stomach is rare, but sometimes Hemor- . . rhage from occurs, taking place in gastric ulcer or cancer of that stomach, organ. The treatment consists in applying astringents or local styptics, as tannic or gallic acid. Tannic acid, applied to a wound, coagulates the blood; but when given internally, is changed into gallic acid ; hence, if bleeding be from the stomach, give tannic acid, and if from some organ remote from the stomach, give gallic acid. The dose is ten grains, repeated in twenty or thirty minutes. Blood coming from the nose or mouth is often swallowed, in which case it undergoes a change in the stomach which gives it the appearance of '' coffee grounds." In vicarious hemorrhage, instead of bleeding from vicarious, the uterus, the blood passes through different channels ; as there must be some outlet, this form is not arrested. Hemorrhage from the bowels occurs in typhoid fever. Bowels. or any ulceration of the bowels, or disease of the rec- tum. The patient may suffer from all the general symp- toms, or the first indication of any serious trouble may be in the passage of a "bloody stool," composed of tarry, black masses. The loss of blood into the intes- tines is attended by the same result as direct loss from the body itself, as after it passes into the intestines it is lost to the system. It undergoes no change, and 8o SURGICAL NURSING. may be passed in its natural color. Opium or tannic acid suppositories are usually given, with injections of alum or plain ice-water, and cold applications to the abdomen. Starch and laudanum injections are also given. Rectum To control hemorrhage from the rectum, the " Catheter en chemise " is employed. To prepare this instrument, take a square of lint, from i^^ inches to 2 inches in size, cut a small notch in the center, through which pass the catheter, secure the lint by means of a bit of silk, and the instrument is ready for use. There is always more or less flatulency about the rec- tum ; the opening in the catheter permits the gas to es- cape, and so lessens the pain ; the lint at the end gives the surgeon complete control of the packing he may wish to insert, as it is impossible for any substance to pass beyond the lint. In hemorrhage from the male bladder the same instrument is employed. CHAPTER IX. WOUNDS AND THEIR COMPLICA- TIONS. Different Kinds of Wounds— Management and Dressing- Constant Irrigation— Wounds of Scalp; Neck ; Chest ; Abdomen— Treatment of Shock— Complications of Wounds— Abscess— Stitch Abscess— Kinds of Pus— Cellulitis— Erysipelas— Poisoned Wounds— Inflamed Lymphatics — Pyemia — Tetanus— Ulcers— Burns and Scalds. Wounds may occur from a variety of causes, and may Different be conveniently divided into : Ificised, where the wound wounds. is a clean cut, produced by some sharp instrument, with- out further injury to the skin and soft parts. Contused and lacerated wounds, which are accompanied by more or less damage to the skin and soft parts; in severe cases the skin may be partly destroyed and the tissues bruised and torn. These wounds are usually produced by gunshot accidents or explosions, or by blows or blunt instruments. An incised wound, if of superficial extent, will quickly ^^^^^^^ heal if properly attended to. Any dirt should be washed off and the wound thoroughly disinfected ; the edges are then brought together by strips of adhesive plaster, and an antiseptic or sterile dressing applied. Extensive 8i Contused and 82 SURGICAL NURSING. and deeply incised wounds are accompanied by severe hemorrhage. After the bleeding has been stopped, it is often necessary for the surgeon to insert some sutures to keep the edges of the wound in apposition so that the healing may be by primary union. Confused and lacerated wounds seldom heal by pri- lacerated mary union, as it is necessary for new skin to form where wounds. 1 J 1 • the old skm was destroyed, and the deeper parts of the wound must first unite before the surface heals over; hence the process of healing is much slower, and the cicatrix is more distinct and permanent. Manage- The management and dressinof of wounds, whether ment and ° ° ' dressing, accidental or after operation, frequently devolve upon the nurse, who should observe strict asepsis in all her preparations. The necessary dressings, — also dressing forceps, scissors, probe, syringe, basins, and solutions, — should be in readiness, the soiled dressings removed as gently as possible, and the wound thoroughly cleansed and disinfected with bichlorid solution i : 2000 before a fresh dressing is applied. Where sutures have been used the nurse should be careful not to pull them, and should also notice whether there be any redness or in- flammation about the edges of the wound, and report to the surgeon. If strapping is to be used, the plaster should be cut into strips of the desired width and length and heated either by means of an alcohol lamp or by wetting in boili7ig water. In some wounds of the extremity, especially when the joint is involved, splints will be required to keep WOUNDS AND THEIR COMPLICATIONS. S;^ the parts at rest. The splint should be previously- fitted and well padded with oakum or cotton, covered with a bandage. If there is danger of oozing from the wound, the padding should be protected by a piece of oiled silk or paper. In some cases constant irrigation is maintained. Constant mi - • T 1 1 1 r 1 • • irrigation. This is accomplished by means of a glass irrigator ; several strands of wicking are passed through the lower opening, by which the quantity of solution falling upon the wound may be regulated. The irrigator is suspended in such a manner that the solution falls directly upon the wound, which is pro- tected by several layers of gauze. A I : 5000 or I : 10,000 solution of bichlorid is generally used, kept at a tem- perature of 110° F. When continuous irrigation is ordered, it is necessary protectioji to carefully protect the bed with a large piece of dress- ° ing rubber; another piece of rubber should be placed under the limb, the upper edges being securely held in place about the limb by means of a patent clothes-pin or a safety-pin, so that the water can not flow back under the patient. The lower edges of the rubber are arranged to drain into a waste-pan or bucket, or an operating pad may be placed under the limb and drained into the bucket. When the dressing rubber is used, a wad of absorbent cotton or oakum should be placed in the hollow usually found at the upper end of the rubber, to catch the water running back. In some cases it is possible to prop the mattress a little to assist in the draining. But 84 SURGICAL NURSING. under the best of circumstances the greatest care will be required to keep the bed and the patient dry, and the irrigator replenished with solution at the indicated tem- perature. Wounds of Wounds of the scalp are of frequent occurrence. The hair for a considerable distance about the wound should be cut very short or shaved, and the wound thoroughly cleansed and disinfected. When it is neces- sary to close the wound with sutures, drainage is secured by means of a few strands of catgut or horsehair. A sterile dressing is then applied, held in position by a capeline bandage. In persons addicted to intemperance, inflammatory action frequently occurs, with suppuration and, perhaps, erysipelas. The nurse should carefully examine the parts about the wound, and notice if there be any swell- ing or bagging, indicating the formation of matter, or if there be any flush or redness, and report it immedi- ately. Wounds of Wounds about the neck are often the result of suicidal the neck. , . , , . intent, and require more than ordinary care to prevent the patient from accomplishing his desire. Those most frequently met with are cut throats. In desperate cases the hemorrhage is so severe as to prove fatal in a short time. Where the larynx has been severed there is danger of suffocation. If there be evidence of this, the patient should be placed upon his side or face, and the wound left uncovered ; and tracheotomy will probably be per- formed. WOUNDS AND THEIR COMPLICATIONS. 85 After the wound has been dressed, the position of the patient is of great importance. The shoulders should be raised by pillows, and the head bent forward. There is always more or less danger of pneumonia, and the patient should be carefully protected from drafts. The feeding of such a patient is often difficult, and nutrient enemata may be required. Wounds of the trunk which penetrate the cavities of Wounds of the chest or abdomen are always dangerous, and should receive prompt surgical attention. A fracture of one or more ribs is the injury most Chest, frequently seen in injuries to the chest, and will be dwelt upon in a subsequent chapter. A blow or bruise upon the abdomen may produce the Abdomen. most serious result without leaving any visible mark upon the skin. Shock is always pronounced, and death has frequently occurred with no other symptom. • Hemorrhage is manifested by the usual symptoms — increasing pallor, extending to the lips and gums, yawning, sighing, thirst, and dilatation of the pupils. . As in all cases of shock, the patient should be put Treatment 11 11.1,-,. of shock. at absolute rest ; external heat m the form of hot bottles and blankets applied ; hot black coffee, small doses of aromatic spirits of ammonia, or a warm saline injection may be administered in preference to alcoholic stimu- lants. Some surgeons advocate the use of a hypo- dermatic injection of morphin. Thirst is always a pro- nounced symptom, and is best relieved by sips of hot 86 SURGICAL NURSING. Complica- tions of wounds. Abscess. water or injeQtions of hot water. Nourishment may be given by small enemata.* The complications are hemorrhage, inflamma- tion, abscess, cellulitis, erysipelas, blood- poisoning, or pyemia, and tetanus. The treatment of hemorrhage has been given in previous chapters. The presence of inflammation is denoted by its four cardinal symptoms — redness, swelling, heat, and pain. The edges of the wound become red and swollen ; the wound feels hot and painful ; these symptoms increasing gradually, involve the surrounding parts. In addition to these local signs there are often constitutional symp- toms. The patient complains of a sense of chilliness, headache, and pain in the limbs. There is an elevation in temperature, accompanied by a quick pulse, dry skin, and coated tongue. These symptoms should be reported at once. Some- times the inflammation in and about the wound may have been occasioned by the dressing, and will be quickly relieved by a change in the materials used ; or it may be due to the formation of a pus sac, which should be opened and drained. Drainage should always be provided for in deep wounds, to allow them to heal from the bottom up. An abscess is a circumscribed cavity containing pus, and may be the result of a wound, or of disease in the soft tissues or in the bones. * Before giving a nutritive or stimulating enema, the bowels should be thoroughly evacuated by a simple soap-suds enema. WOUNDS AND THEIR COMPLICATIONS. Sy An abscess may point or protrude at one point ^nd break spontaneously, or it may be necessary for the surgeon to open it. In either case the character of the discharge bhould be noticed. A stitch abscess is a small collection of pus formed stuch^^ at the insertion of a suture, and quickly disappears when the infected suture is cut and removed. Healthy or laudable pus is of a yellowish color, Kinds with a faint, sweet odor, and when coming from the surface of a granulating wound may be streaked bright with blood, as the granulations bleed easily. The discharge from an unhealthy wound or an abscess is greenish-yellow or green, dark brown or red from de- composing blood, and offensive or even putrid in odor. After the cavity has been evacuated, it should be Treatment, thoroughly cleansed with warm bichlorid or some other antiseptic solution, either by means of an irrigator or syringe, and a sterile or wet antiseptic dressing applied. Sometimes the cavity is packed with gauze or a drainage- tube is inserted. When a wet dressing is used it should be thoroughly covered with absorbent cotton and oiled paper to keep it moist, and should be changed once or twice during the day. Cellulitis is a form of inflammation which attacks Cellulitis, the cellular tissues. It begins about the margin of the wound, but if not speedily controlled, rapidly extends for some distance into the surrounding parts. The affected tissue becomes very much swollen, red, and extremely painful, and is accompanied by an elevation SS SURGICAL NURSING. in temperature. Free incisions are generally made and one or more drainage-tubes introduced. Dressings of gauze or oakum, wet with bichlorid solution i : 2000, are usually applied. Erysipelas. Eryslpclas may be superficial, attacking only the skin, when a bright-red rash, having a distinct margin, appears about the wound. It spreads rapidly, with more or less swelling underneath, usually lasting from eight to ten days. A more severe form closely resembles cellulitis, and vesicles or blisters appear, containing clear fluid, which soon becomes turbid. The constitutional symptoms are well marked by a chill or rigors, elevation in temperature, and the usual fever symptoms. The disease is highly contagious to others suffering from open wounds, and in a hospital the patient is iso- lated. Nourishing diet and, in some cases, stimulants are administered; perfect cleanliness and good venti- lation are absolutely essential. x\ll soiled dressings should be removed at once; instruments or splints used in redressing such a case should never be employed about other patients. At the termination of the disease the room, bedding, and all the instruments or utensils used should be thoroughly cleaned and disinfected. Poisoned Any cut, abrasion, or wound may become poisoned, either from the introduction of septic material or from the foulness of its own discharge. The usual treatment is the application of a wet antiseptic dressing. WOUNDS AND THEIR COMPLICATIONS. 89 The first symptom that the lymphatics are becoming Jj;^fp'j;^fi^g inflamed is shown in a faint blush running up the limb in the course of the vessels, with a sensation of pain and stiffness, and should be at once reported. Pyemia, the most severe form of blood-poisoning, Pyemia, is marked by a sudden and severe rigor of some dura- tion. The patient's teeth chatter and he becomes cyanosed; the temperature rapidly rises to 104° or 106°, or even higher. This is followed by a period of pro- fuse perspiration. These rigors are a distinct feature of the disease, and usually occur at intervals, often of twenty-four hours. The, wound and the general condition of the patient become rapidly worse ; abscess may appear in different parts of the body, in the joints, internal organs, or ex- ternal tissues. Very little can be done except to keep up the nourishment and exercise great care in the ven- tilation of the room. During the rigors the temperature' should be taken, some warm drink administered, and additional bed- covering applied. Acute cases result in death in from two or three days to two weeks. Tetanus, or lock-jaw, may attack patients suffering Tetanus. from any kind of a wound, whether slight or severe ; but it is generally supposed that the risk of contracting the disease is greater when the injury sustained is in the hand or foot, and inflicted by a rusty instrument. It frequently results from a ''sliver," the microbe or germ being carried into the system by this tiny piece of wood. 7 90 SURGICAL NURSING. The disease is characterized by a spasm or cramp of the muscles of the body of a most painful nature. The early symptoms are often very slight ; usually a feeling of stiffness about the jaws' and throat, rendering eating difficult, as the patient is unable to open his mouth. This is followed by more severe spasms, in which the muscles of the trunk become -firmly contracted, and the face is drawn into a grinning expression. As the spasms increase a larger number of muscles become affected, the head is drawn back and the body arched, with the abdomen forward ; breathing may cease and the face become livid. Death usually results from suffocation or exhaustion. Less severe cases sometimes recover. Treatment. The patient should be at once isolated and be kept perfectly quiet, as the spasms are frequently started by the least noise, or even a draft of air, or by touching the bedclothes. A small gag of some sort should be kept in the patient's mouth to protect the tongue from being bitten during the spasms, and to prevent the jaws from be- coming rigidly closed. The feeding is of great importance, and should be carried on between the convulsions, the nourishment being administered frequently and carefully. Some narcotic, such as chloral, is generally given to induce sleep. Where there is an open wound, it should be thoroughly cleansed and an antiseptic dressing applied. Ulcers. An open sore left as the result of an injury, or occa- sioned by inflammation of the skin or mucous mem- WOUNDS AND THEIR COMPLICATIONS. 9 1 branes, or from constitutional or local disease, is called an ulcer. A healthy ulcer is covered by small red granulations, exuding yellowish pus, and is surrounded by healthy skin, showing a bluish line at the circum- ference. The size of the ulcer diminishes daily, as the skin heals over, under the influence of rest and some simple dressing. In unhealthy ulcers the skin around the margin looks inflamed, the granulations are swollen or covered with a slough, and there is a discharge of unhealthy pus. Indolent ulcers are very slow in healing. The margin is white and indurated, the granulations pale and flabby with but little secretion from the surface. Stimulating applications are indicated, and great attention should be given to the general health. All ulcers should be thor- oughly cleansed, and afterward disinfected with bichlo- rid or other antiseptic solution. Old indolent ulcers do well when they are thoroughly washed with warm sterile water and Castile soap and disinfected with a solution of permanganate of potassium followed by bi- chlorid. In many cases firm support is given by means of strapping. The bandage is usually applied in a "figure-of-eight" for additional firmness. When the ulcer is situated in the lower extremity, rest in bed will prove of great benefit. Strapping for ulcers is usually cut about one inch in width and long enough to extend for some distance beyond the margin on each side. In applying the strips, the end on one side should be scalds. 92 SURGICAL NURSING. first fixed and firm traction made in fixing the remaining end, each strip overlapping about one-half. When old strapping is to be removed, pull gently from both ends of the plaster toward the center. Burns and Destruction of the skin and soft tissues of the body is the result of dry heat in burns and moist heat in scalds. The severity of the burn is indicated by the extent of surface destroyed and by the amount of shock sus- tained. Burns or scalds of any magnitude are accompanied by profound shock, which should receive the usual treat- ment before the local injury is dressed. Air should be excluded from the wound as quickly as possible, and while awaiting the arrival of the surgeon, the patient may be immersed in a warm bath, the temperature of the water being regulated by the sensation of the patient. When the wounds are to be dressed, only a small part of the surface should be exposed at one time. If there be vesicles or blisters of large extent, they should be snipped at their dependent edge, and the fluid soaked up with absorbent cotton, but the skin should not be removed ; small vesicles may remain untouched. The first dressing often consists of carron oil (equal parts of linseed oil and lime-water), applied on pieces of lint, or an ordinary sterile dressing may be used. Some surgeons prefer some of the antiseptic ointments, such as boric acid or iodoform, which should be spread upon lint, covered with gauze and absorbent cotton, and retained in place by a bandage. Boric-acid WOUNDS AND THEIR COMPLICATIONS. 93 solution is used instead of bichlorid for washing off the wound. Burns become very offensive, and, whenever it is possible, a patient suffering from them should be isolated. The scars resulting from burns are often very disfiguring, and when the injury is in close proximity to a joint or about the throat, there is often great de- formity, in spite of various splints used to prevent it. CHAPTER X. FRACTURES— DISLOCATIONS- SPRAINS. Emergen'cy Cases in General — Classification of Frac- tures— Special Fractures. Treatment As fractures and dislocations belong to a class of ofemer- . ° gency cases cases which mav be called emergencies, it may not in general. . . . •' come amiss to give a tew directions for the treatment of emergency cases in general. If the nurse precedes the surgeon upon the field of accident, she should at once ascertain the correct name and address of the injured person ; how and under what circumstances the accident occurred. These in- quiries need occupy but a few minutes, and frequently save much time and annoyance. If hemorrhage be present, it should be arrested by some one of the means given in a previous chapter. If a limb be severely lacerated or fractured, a temporary splint must be applied. This may be constructed from almost anything — a pillow, a firmly rolled blanket, a thin piece of board, a gun securely bandaged to the leg, or, if no material be at hand, an injured leg may be bound to its fellow to give support. The splint should extend far enough above and below the injury to hold the nearest joint at rest. 94 FRACTURES — DISLOCATIONS — SPRAINS. 95 The utmost care is necessary in handling a fracture, any roughness tending to lacerate the soft parts, or causing the fragments of bone to protrude, thus con- verting what was originally a simple fracture into a compound fracture. In moving the patient one person should support the fractured limb, and before trans- porting him upon a stretcher both legs should be tied together, to prevent the injured one from rolling out- ward. In removing clothing from an injured person the sound limb should be slipped out of the garment first ; in removing trousers always be sure that the suspenders are first unfastened. In cases where there is a great deal of pain or danger in moving a limb the outer seam of the garment may be ripped w.-^. In severe injuries shock is always present, and should receive treatment as soon as possible. Where pain is severe, a hypodermatic injection of morphin is given. A fracture is the solution in the continuity of a Definition bone, and may be caused by: (i) Direct violence ; as of fracture, when a falling body strikes the clavicle, fracturing the bone. (2) Indirect violence ; as when a person falls, striking the shoulder first, thus fracturing the clavicle. (3) Muscular action ; as when the patella is broken by powerful contraction of the quadriceps. (4) Contre- coup ; as when a blow upon the head causes fracture, not at the point of contact, but at the opposite point on the skull. Fractures are classified as follows : Simple, where the bone alone is broken, with nociassifica- . 1 J tion of external wound. fracture. 96 SURGICAL NURSING. Compound, when there is an open wound com- municuiing with the seat of fracture. Comminuted, where the bone is broken in more than one place. Incomplete, or " green-stick," where the bone is only partly broken ; this fracture occurs usually in young children. Impacted, when one end of the bone is driven into the other. Symptoms. The symptoms necessary to prove the existence of a fracture are: (i) Deformity; (2) abnormal niobility ; (3) crepitus. Fain and sivellingd^xt almost constant acco^npaniments of fracture, and are attended by heat and redness. In fracture due to direct violence the soft parts are liable to be injured, showing at a later period in the form of sloughing. Fractures caused by indirect violence are often fol- lowed by extravasation of blood beneath the skin (ecchymosis), generally at some distance from the seat of fracture. Crepitus, the rough, grating sensation conveyed to the ear and hand of the surgeon when the broken ends of a bone are rubbed together, can not be heard in an impacted or a *^ green -stick " fracture when there is a gap between the ends of the bone, or when the soft tissues intervene. Compound CoHipound fractuFes are always dangerous; the degree of danger is not so much dependent upon the fracture as upon the entrance of air into the wound, and upon injury to the surrounding tissues. FRACTURES — DISLOCATIONS — SPRAINS. 97 After the hemorrhage has been checked, the wound should be thoroughly cleansed and disinfected by the use of bichlorid solution and a syringe, the surrounding parts shaved, and a sterile dressing applied. Small wounds are sometimes closed with tr. benzoin, comp., applied on several layers of gauze of sufficient size to overlap the margin of the wound. As shock is generally present, the precaution of uncovering the patient as little as possible, even in summer when the surrounding atmosphere is warm, should bf observed. In lifting or holding a fractured limb grasp it firmly and hold it steadily, being careful to support it above and below the seat of fracture, making gentle traction. In fracture of the forearm always hold the arm midway between pronation and supination, or with the thumb up, to keep the proper relation of the bones. The same rule should be observed in applying a sling. The difference between a fracture and a dislocation Difference' can, in the majority of cases, be readily determined by fra^ure the use of traction ; the deformity will disappear but ideation, upon relaxation again show itself in 2. fracture, while in a dislocation the deformity, once reduced, does not return. The treatment of a simple fracture consists in Treatment .of simple reducing the deformity by firm, gentle extension, to fracture, bring the ends of the bone in apposition, and retaining them in this position by means of splints or fixed dressings. As reduction of a fracture is attended by some risk in the hands of an inexperienced person, the better plan for a nurse is to apply any simple dressing 98 SURGICAL NURSING. which will keep the part at rest until the arrival of the surgeon ; the best position being that which is most comfortable to the patient. Fracture of In fracturc of the skull signs of concussion are the skull. . ^ generally present, accompanied by pallor, feeble res- pirations, and more or less unconsciousness. In a depressed fracture there are symptoms of compression of the brain, which are : Complete loss of consciousness ; respirations slow and labored; pulse slow and hard, like a sledge-hammer; the pupils of the eyes are fixed, usually dilated, and do not respond to light. In such a case, in all probability, ''trephining" will be performed. In simple fracture without evidence of compression, perfect quiet and good nursing constitute all the treat- ment required. The patient should be kept in a darkened room, given light diet, and the bowels kept freely moved, usually by small doses of calomel. The hair should be closely cut and an ice-bag applied to the head. The patient is usually kept in bed about three weeks. In a compound fracture the wound requires the most careful attention. The entire scalp should be shaved, the wound thoroughly cleansed and disinfected with bichlorid solution i : 5000, and a sterile dressing applied. Convulsions may result from a compound fracture of the skull, in which case the nurse may only cleanse the wound with the utmost care, and await the arrival of the surgeon. FRACTURES — DISLOCATIONS — SPRAINS. 99 In fracture at the base of the skull there may be Fracture •^ "'at the base. hemorrhage from the nose, pharynx, or ear. The escape of cerebrospinal fluid from the ear, or of brain matter through the nose or pharynx, is conclusive proof of fracture at the base. As septic germs may enter through the ear, nose, or mouth, great care should be given these organs. The ear should be thoroughly cleansed from blood, dirt, or wax, and irrigated with warm corrosive sublimate 1 : 5000, and is then often packed with gauze and covered with a sterile dressing. The nose should be kept clean by the use of boric acid or dilute peroxid of hydrogen \ the mouth by Listerine or Seller's solution ; and the eyes with warm boric-acid solution. Fracture of the clavicle is very frequently met F/acture •' . ^ of clavicle. with, and the position assumed by the patient is so characteristic that a diagnosis can almost be made by that alone. The head is inclined toward the injured clavicle ; the shoulder slopes more than in health, and is drawn more to the center of the body; the arm is supported at the elbow by the other hand. The fracture is usually dressed with a Sayre's dress- ing or Velpeau's bandage. The nurse should have in readiness plenty of bandages (2^ and 3 inches in width), adhesive plaster and the means of heating it, two small pads of lint, and a folded towel or lint for the axilla. In case of emergency a very effective appliance may be made from two good-sized handkerchiefs or pieces of muslin about ij^ feet square. Fold each hand- lOO SURGICAL NURSING. kerchief toward the center until the two opposite corners meet ; then fold it into a band about four inches wide. Pass a handkerchief thus folded around each shoulder, and tie the ends in a single knot over the scapula ; then draw the shoulders well backward and hold them in this position by tying the two ends of the right handkerchief to the two ends of the left. The arm is then flexed upon the chest and a sling applied to support the forearm and elbow. Sometimes the fracture is treated by placing the patient in the recumbent position, with a small sand-bag under the scapula of the injured side, and the shoulder is then weighted with anything which will steady it. Fracture Probably, of all fractures this is the one in which of the shaft . . i -i , • i of the non-union is most likely to occur, owing to the great leverage of the lower fragment and the difficulty of keeping the parts perfectly immobilized. Non-union may also be due to the interposition of muscle or fascia between the fragments. After the fracture is reduced, immobilization is secured by the application of a shoulder-cap splint (made of heavy binders' board), reaching to just above the elbow, and a short internal splint, both held in position by a firmly applied bandage. The arm is carried in a sling, the elbow unsupported. Sometimes w^hen the patient is a muscular man, a weight is attached to the elbow. A light plaster-of- Paris dressing is sometimes applied. Fracture This fracturc is treated by the application of an ante- of the . . ^ radius and rior and a posterior splint, carefully padded a little higher through the center, to keep the bones apart. The FRACTURES — DISLOCATIONS SPRAINS. lOI splints are made a little wider than the diameter of the forearm, so that when the bandage is applied it exerts no lateral pressure. The forearm is carried in a sling midway between pronation and supination, or, in other words, with the thumb up. The bandage should always be applied with the elbow flexed, and the fingers should be watched to see that circulation is not interfered with. Fracture of the lower end of the radius, or Colles'' Coiies' fracture, is also very common, and presents a marked ^'^^''*"'^^' and peculiar deformity which resembles a '' silver fork," and is called by that name. The back of the hand looks unusually long, and shows a prominence just above the carpus, or wrist, due to the lower fragment being driven backward. Immediately above it is a depres- sion, because the lower and upper fragments are not in line. On the palmar surface, just above the carpus, is a depression, and just above this a prominence. The fingers are flexed. When once the fracture is properly reduced, there is small danger of its becoming again displaced, so the matter of splints is of small importance. It may be dressed with a '' Bond " splint, or with two straight splints, the posterior one ending at the wrist and the anterior one extending to the palm, with a pad on its lower end, over which the fingers rest. A plaster-of-Paris dressing may be applied, or simply a band of adhesive plaster may be carried around the wrist to give support, allowing free motion of the fingers. When the anterior or posterior lip of the radius is broken off, it is called a Barton's fracture. fraSe" I02 SURGICAL NURSING. Fracture External violence is the most common cause of '^ " ^' fractured ribs, but muscular contraction in severe paroxysms of coughing has produced the same result. The pain is speedily relieved by giving firm support to the chest wall. This is accomplished by passing broad strips of adhesive or mole-skin plaster around the body from spine to sternum, each successive strip overlapping the other one-half; additional support is sometimes secured by reinforcing this with vertical strips. This strapping is also very effective in pleurisy. The pleura and lungs may be injured by ends of the broken bone, causing difficult and rapid breathing, with much pain. Pneumonia is also a complication to be guarded against. Pelvis. Serious injuries are frequently met with about the pelvis, in all of which the treatment consists in securing immobilization, either by means of a strong girdle, plaster of- Paris cast, or Buck's extension. The patient should be kept in the recumbent position, and the nurse should notice whether urine be passed after the accident, and whether blood be present, and save a specimen for examination. Fractured A fracturc of the spine at any point is a serious thing, because the risk of compression, laceration, or contusion of the spinal cord is very great, and the result of such injury far-reaching. Paralysis of motion and sensation, loss of control of the bladder and rectum, bed-sores, and a condition of utter helplessness render such cases very pitiful. Fracture of the spine at the neck is always fatal ; at spine. FRACTURES— DISLOCATIONS— SPRAINS. I 03 the dorsum, the nerve-centers are much affected. There is always complete paralysis below the seat of fracture, the bladder and rectum both being involved. Reten- tion of urine changes to incontinence of both urine and feces. Place the patient upon his back ; if possible, upon a water-bed. The greatest care will be necessary to prevent bed-sores. Keep the bed perfectly dry and smooth; bathe the patient daily and rub the body briskly with a coarse towel or brush, using alcohol and alum for hardening the skin. Even with a water-bed, it is necessary to resort to the use of rings and change of position to prevent pressure. The femur may be fractured at the neck, ^r|HHr O'DwYER's Intubation Scale, Set. Fig. 40. 123 Larynx Tube. 124 SURGICAL NURSING. Fig. 41.— Frame for Hip-joint Disease. Fig. 42.— Covered. NURSING SPECIAL CASES. 1 25 theria, croup, and in some cases of dyspnea caused by burns or scalds, and in pressure upon the larynx from tumors. When the tube is to be inserted, the nurse holds the child upright on her lap, with its arms controlled by a sheet. An assistant holds the child's head, and at the proper moment inclines it backward. The child is held in the same position for the removal of the tube. There is always danger of the tube slipping when the child coughs ; when this occurs, the nurse should insert the mouth-gag and press the tube back into position. Fig. 43. — Frame for Hip-joint Case. Great care is also necessary in feeding the patient that the tube does not become displaced. Hip disease, and the operations resulting from it, Hip disease are exceedingly trying in children, on account of theti"n1n^chii- difficulty experienced in keeping them quiet. ^^^"' This difficulty is overcome in some hospitals by the use of a frame, fashioned like the accompanying illus- tration, the head being a little broader than the foot, to give the shoulders plenty of room. A piece of canvas is securely fastened, by means of straps and buckles, across each end, reaching from the 126 SURGICAL NURSING. end to the enlarged opening in the center, which is de- signed for convenience in dressing the hip. A small sheet is then folded to fit the frame, and is securely pinned in place on the under side. The child is placed upon the frame and held in posi- tion by a broad band passed about the frame over the chest. The children are quite comfortable, and can be easily moved by simply lifting the frame. In this manner they Fig. 44.— Triangular Hip Bandage. can be taken out of doors or placed upon cots, the exten- sion still being applied. Triangular ItiwiU also be fouud that much pain can be saved the bandage in hip chess- little suffercr by using the triangular bandage in dress- ings. . . . ing the hip, doing away with the lifting and straining which are almost unavoidable in applying a spica. The bandage should be made of light muslin or cheese- cloth, and folded as in the illustration, the dotted lines representing the lower edge folded over. In applying the bandage, the longest end is passed under the back, far enough to reach more than half way around the waist, the other end being passed over the NURSING SPECIAL CASES. 127 anterior aspect of the thigh, then under, and up to the waist line, to meet the other end of the bandage, where it is secured with a safety-pin ; the lower edge is fitted Fig. 45.— Triangular Hip Bandage Applied. Fig. 46.— Triangular Hip Bandage Applied. neatly around the limb, and also secured with a small safety-pin. A little practice will render the nurse very deft in the 128 SURGICAL NURSING. application of this dressing, which remains firmly in place and is comfortable. It is also an excellent bandage to use in case of psoas abscess, even with an adult, as it can be made in any size. With children, special care is also necessary in regard to the extension, keeping careful watch of the Fig. 47. — Cradle. Amputa- tions. condition of the skin, which is very apt to become ex- coriated from the plaster. The same general rules apply to amputations as to all other operations, the great danger being from hemor- rliage, which may occur soon after the operation, or some days later. In order to prevent it, the limb should be elevated upon pillows ; sometimes the foot of the bed is elevated. The stump should be lightly covered, a NURSING SPECIAL CASES. I 29 ''cradle," or wire frame, being placed underneath the bedding to prevent pressure upon the limb. Where hemorrhage is expected, a tourniquet is some- times loosely applied, and can then be easily adjusted ; or Esmarch's rubber tubing may be conveniently at hand. The patient should be kept quiet, and carefully watched until all danger of hemorrhage is past, which, in case of a hip-joint or thigh amputation, may not be for two weeks. Care should also be taken that the patient does not hit the stump during his restless- ness. In raising the stump, never lift it from the end, but pass the hand gently between the limb and the pillow from above, supporting it steadily while the pillows are being changed or the dressing done. Stump dressings vary in shape as the surgeon may pre- fer, sometimes being made in the form of a *' Maltese " cross, or a , but more frequently a simple oblong dressing of sufficient size to come well up on the stump is used. Firm traction is made in applying the bandage, and the entire dressing is prevented from slipping by straps of adhesive plaster. CHAPTER XII. BANDAGING. Use of BandaCxES — Materials Employed — Dimensions — Kinds— Method of Rolling Bandage — General Rules FOR Applying— Special Bandages. Use of bandages. Materials used. Bandages constitute a very important part of all sur- gical dressings, and are employed to retain dressings in position, to make pressure, and in the adjustment of splints. They may be prepared from muslin (bleached or un- bleached), linen, crinoline, cheese- or tobacco-cloth, flannel, or rubber sheeting. The unbleached muslin is commonly used on account of its cheapness, but bleached muslin, which has been previously washed, is much better. Crinoline is usually employed in the preparation of plaster-of-Paris bandages, but is also used by some surgeons without the plaster, in which case it is first wet, and as it dries upon the part gives a firm support. Cheese- or Tobacco-cloth is employed in many cases to confine the first dressing, as it adapts itself more readily to the part, so retaining the dressing in better position. It is also largely employed in preparing the plaster-of-Paris dressings, 130 BANDAGING. I3I The Rubber bandage is used in operations upon the extremities, and also to reduce swelling and give firm support to a limb. Flannel bandages are used for the head, eyes, on the limbs, to prevent or reduce swelling, and underneath plaster-of-Paris dressings. Bandages vary in length and width according to the Dimen- purpose for which they are employed. Those most^'°"^" frequently used are : One inch wide, three yards in length, for hand, fingers, and toes. Two inches wide, five yards in length, for the head and for the extremities in children. Two and one-half vi\Q}cit% wide, seven yards in length, for the extremities in adults. Three inches wide, nine yards in length, for thigh, groin, and trunk. Bandages may be roughly divided into simple and Varieties of double rollers, and the handkerchief or triangular ^"'^^^^^• bandage. The Roller bandage consists of a strip of some one of the materials previously mentioned, of a suitable length and width for the purpose for which it is to be employed, and for convenience in application is rolled into a firm cylindric ball. The bandage should consist of one piece, free from seams and selvage, for if there be seams or creases in the bandage it can not be neatly applied, and is apt to be uncomfortable to the patient. It should also be free from all loose threads, and for this reason all material used, with the exception of cheese- or tobacco-cloth, should be torn into strips, not cut. With cheese-cloth it is necessary to cut by a drawn thread, in order to Method of rolling 132 SURGICAL NURSING. secure an even edge. Every nurse as well as physician should be able to roll a bandage firmly and evenly either by hand or machine. To roll a bandage by hand the strip should be folded bandage, at one extremity several times until a small cylinder is formed ; this is then grasped by the thumb and index finger of the right hand ; the free extremity of the strip is held securely between the thumb and index finger of the left hand, and by alternate pronation and supina- tion of the right hand the cylinder is turned and the roller formed. The firmness of the bandage is regulated by the amount of tension which is made upon the free extremity of the bandage during the revolutions of the cylinder. There are several machines made for winding band- ages, all working upon the same general principle. The '* Jobse" is to be preferred, as it has a guide to keep the bandage even, and by the adjustment of an under screw can be attached to any table or chair. A single bandage rolled into the form of a cylinder is called a single or single-headed roller ; if rolled from each extremity toward the center, it is called a double or double-headed roller. A roller bandage may be described as consisting of an initial extremity, the free end of the bandage; a terminal extremity, the end of which is inclosed in the center of the cylinder; a body, that portion be- tween the extremities; and two surfaces, an internal and an external surface. General In applying a roller, fix the external surface of the BANDAGING. 133 Fig. 48. — Bandage Roller. Fig. 49.— Bandage Roller. T34 SURGICAL NURSING. initial extremity upon the part, holding it in position with the fingers of the left hand, until firmly fixed by a few turns of the roller. In this way the operator has more control over the bandage. Care should also be taken that the turns are applied smoothly to the surface, and a uniform pressure exerted throughout the length of the bandage, each fold overlapping the other equally, and all reverses coming on the outside of the limb. Care should also be taken that the limb is in the_position that it is to occupy, as regards flexion and extension, upon the com- pletion of the dressing. A bandage applied when the limb is flexed will exert too much tension when the limb is extended, and so may become very uncomfort- able and even dangerous to the patient. When the bandage has been applied the terminal end is secured by means of a small straight pin or safety-pin inserted in such a manner that the point is buried in the folds of the bandage. If the bandage be narrow, the end may be split, and the two tails secured around the part by tying. To remove In removing a bandage, the folds should be care- age, ^^j^y gathered up into a loose mass and rapidly trans- ferred from one hand to the other as the bandage is unwound. If the bandage be cut, scissors especially designed for the purpose, having one blade longer than the other, the point protected by a guard, which may be readily slipped under the bandage, will be found more conve- nient. bandlge. ^^ circular bandage consists of a few circular turns BANDAGING. 135 around a part, each turn covering accurately the pre- circular ceding turn. This bandage may be used to a limited ^^"^^^^• Fig. 50. — Bandage Scissors. bandage. Spiral bandage. portion of the head, neck, or limbs, or to make com pression upon the veins before venesection. In the oblique bandage the turns are carried obliquely oblique over the part, leaving open spaces between the turns. It is employed to retain tempor- ary dressings. In the spiral bandage the turns are carried around the part in a spiral direction, each turn overlapping the preceding one-half or one-third. This bandage may be used to cover a part which does not increase in size too rapidly, such as the abdomen, chest, or arm. The spiral reversed differs from the spiral in having spiral its turns folded back or reversed, as it ascends a limb the diameter of which gradually increases. Fig. 5 Spiral Bandage OF THE Finger. reversed. Fig. 53.— Spiral-reverse, of Lower Extremity. 136 BANDAGING. 137 To apply the bandage, the operator should stand in front of the subject, and after fixing the initial extremity of the roller, the bandage is carried off a little obliquely to the axis of the limb; the index finger or thumb of the disengaged hand is placed upon the body of the roller to hold it securely in position ; the unwound por- tion of the bandage is slackened, and by changing the position of the hand from extreme supination to prona- tion the reverse is made. Care should be taken not to attempt to make a reverse while the bandage is tense, for it is im- possible to make it evenly, and it is therefore uncomfortable to the patient. Complete the re- verse before carrying the band- age around the limb, and when it has been completed the band- age may be slightly tightened to conform closely to the part. The reverse should not be made over the bone, but upon the outer portion of the limb, each turn being in line with equal tension, in order to present a good appearance, at the same time proving comfortable to the patient. This bandage is used to retain dressings upon the extremities, in applying extension, and to give support to the limb. When the turns of a roller cover each other obliquely, spica. leaving the previous turn about one-third uncovered, the bandage is known as a spica bandage. This bandage is used to retain dressings upon par- 10 Fig. 54. — Spica, of Instep. 38 SURGICAL NURSING. ticular portions of the surface of the body, such as the shoulder, groin, or foot. In applying the bandage to Fig. 55.— Figure-of-eight of Ankle. Fig. 57.— Recurrent Bandage of Fig. 58.— Recurrent Bandage Stump. of the Head. the shoulder, the turns are begun at about the middle third of the arm, and upon approaching the upper BANDAGING. 139 third the roller is carried over the opposite shoulder ; in the groin the upper portion of the bandage passes around the waist ; and in the foot the upper turns pass around the ankle. In this bandage the turns are applied in such a man- FiRure-of- ner as to form the figure 8. These turns are used in the age! application of Barton's bandage, the bandage of the knee, elbow, and many others. In the recurrent bandage, the roller, after covering a The recur- certain portion of the surface, is brought back to the l^gl\ ^^"^' point of starting ; it is then reversed and carried toward the opposite point. This manipulation is continued until the part is covered by these recurrent turns; it is then secured by a few circular turns. It is usually em- ployed in the dressing of stumps and in the head dress- ings. Compound bandages|are usually composed of several Compound pieces of muslin or some other material, and are em- ployed to retain dressings to some particular part of the body. The most useful are the T-bandages and the many-tailed bandages. The single T-bandage consists of a horizontal band T-band- to the middle of which is attached another vertical ^^^^' band. The horizontal band should be about twice the length of the vertical piece. This bandage may be conveniently used to retain dressings on the perineum and rectum or to various parts of the body, being modified to meet the requirements of the case. The double T-bandage used in perineal and rectal dressings for male patients has two vertical strips attached to the I40 SURGICAL NURSING. horizontal piece. It may also be used for much the same purpose as the single T-bandage, and will be found convenient in retaining dressings to the chest, breasts, and abdomen. It may also be used to secure dressings Fig. 59.— T-Bandage of the Eye. Fig. 60.— Four-tailed Bandage OF THE Head. Fig. 61.— Eight-tailed Bandage of the Abdomen. to the nose, the strips in this case being about one inch in width. Many- These bandages are prepared from pieces of muslin uikdband-^^ different lengths and widths, which are torn from BANDAGING. 141 both ends into two, three, or more tails, up to within about three inches of the center, their width and length being regulated by the body to which they are applied. They may be used as a temporary dressing in case of fracture of the jaw or clavicle, or to retain dressings upon the chin, scalp, abdomen, and trunk. It is used entirely by some surgeons in cases of laparotomy, in which case the bandage is prepared from a piece of flannel i^ yards in length and about twenty inches in width, being torn into eight strips. The body of the Fig. 62. — The Square. Fig. 63.— Oblong. bandage is placed upon the patient's back and the ends crossed upon the abdomen and secured by safety-pins. The handkerchief bandage may be used for a variety Handker- of cases to great advantage in the temporary or perma- agL^ nent dressing of wounds, fractures, or dislocations. The handkerchief or square may be converted into an oblong, made by folding the square once or twice upon itself. • The triangle, made by bringing the diagonal angles The trian- of the square together, the line of folding being known ^ ^' 142 SURGICAL NURSING, Fig. 04.— Trianglk. Fig. 65. — Folded for Hip. Fig. 66. — Triangle Applied to Head. X ^ r \ i^^^ Fig. 67. — Cravat. BANDAGING. I43 as the base, the angle opposite the base the apex, and the other angles, the extremities. It is used to confine Use. dressings to the thigh or head. To apply the triangle to the thigh, the apex is folded a Application little more than half way to meet the base, as shown in the accompanying illustration ; the longest extremity is then passed under the back and brought across to the opposite hip, the other extremity being carried obliquely over the anterior aspect of the thigh, then under, when it is carried up the posterior aspect to the waist line, where the bandage is secured ; the other intersections are also securely pinned with small safety-pins. In applying this bandage to the head, the base is Head, placed upon the forehead and is then carried to the occiput, where the extremities cross, passing around to the forehead, where they are secured. The cravat is prepared from the triangle by bringing The cravat, the apex to its base and folding it a number of times upon itself until the desired width is secured. The cravat is used to retain dressings in the axilla. Use and and is applied by placing the body of the cravat in the tion. axilla of the affected side, crossing the extremities of the bandage over the corresponding shoulder; then carry them over the chest, one before and the other be- hind, to the axilla, where they are secured. To apply this bandage a piece of muslin i^ yards long folded into a cravat is required. The cord is made by twisting the cravat upon itself. The cord. This form of the handkerchief bandage is used in apply- ing " The Spanish Windlass." 144 SURGICAL NURSING. Bartons Jn Barton's handkerchief, used in making extension handker- , . chief exten- to the leo^ OF thi^h, the handkerchief is folded into a sion. CO narrow cravat, the body of which is placed upon the os Fig. 6S. — Cravat Applied to Axilla. Fig, 69. — The Cord. calcis, below the insertion of the tendo Achilles, so that two-thirds of the cravat come around the outer malleus, BANDAGING. 145 leaving the other third upon the inside; the inside portion being kept parallel with the sole of the foot, the outside piece being carried over the instep and then carried around it forming a knot, and also passed under the sole of the foot and turned around the first turn to Fig. 70.— Liebreich's Eye Bandage. form another knot at the metatarsal articulation, where both ends are carried off perpendicularly from the foot. This bandage consists of a strip of flannel 2>^ inches Liebrdch' wide and from six to ten inches long, to the extremities age.*"^""^' of which are sewed tapes. It is also made of green holland. 146 SURGICAL NURSING. It may be applied to cover both eyes, or obliquely, to cover one eye only, and is secured by carrying the tapes around the head and tying them over the forehead. Bandage of This is a compound bandage consisting of a number Scultetus. . ^ ° ° of pieces of muslm, flannel, gauze, or any other material used for bandages. The material selected is torn into strips usually from 2^ to 4 inches in width, long enough to encircle the parts one and one-half times. Method of Begin to make the bandage from above down, allow- making. . ° ° ' Appiica- ^"g ^^^ second strip to overlap the first one-half, and so tion. on until the desired width is obtained. The bandage Pott's Fig. 71.— Liebrhichs Eye Bandage. is then placed under the limb or part to be covered, and the pieces brought into place, beginning from below up. The extremities of the last strip are secured by a small safety-pin. This bandage will be found very con- venient for retaining dressings to the limb in compound fractures, either of the leg or thigh ; also in excision of the hip-joint, where as little disturbance as possible is important in dressing the wounds ; and in cases of laparotomy, bandage. When the strips are attached to each other by a thread or piece of the material through the center, it is known as Pott's bandage. BANDAGING. 147 In preparing either of these bandages for a case of compound fracture or excision of the joint, it will be found very convenient to make it upon a foundation of Fig. 72.— Bandage of Scultetus parchment or waxed paper cut the desired size. When the strips have been arranged upon the paper, fold it evenly upon itself from both ends toward the center, 148 SURGICAL NURSING. leaving a space a little wider than the posterior aspect of the limb ; slip one end under the limb, unfold your bandage and apply, beginning from below upward. When secured, bring the paper up over the limb, so pro- tecting the bed and clothing from all discharge. CHAPTER XIII. FIXED DRESSINGS. Plaster-of-Paris — Bavarian Dressing— Starched Bandage — Gum-and-Chalk Bandage — Silicate of Sodium or Potassium — Paraffin Bandage. A variety of substances may be used in the applica- Fixed tion of these dressings : plaster-of-Paris, starch, silicate ^^^^^"^^' of sodium or potassium, paraffin, or a mixture of gum and chalk. Whatever substance may be employed is first incorporated in the meshes of some open fabric, such as crinoline or cheese-cloth, or is painted over the surface of the bandage. Plaster-of-Paris bandages are most commonly used p^^p^'j.^- and are prepared by taking crinoline, cheese-cloth, or piaster-of- •^ . "^ ° . . Pans band- gauze, which has been previously cut into strips from age. two to four inches in width, five yards in length, and thoroughly rubbing the extra-calcined variety of dental plaster into the meshes. To do this evenly, lay the bandage across a table, rub the plaster evenly over the surface of the material with the left hand, while rolling it loosely with the other. After the cylinder is formed, by giving it a gentle touch it will roll upon itself just loose enough to be right. When the entire bandage has been gone over and rolled, 149 150 SURGICAL NURSING. wrap tightly in waxed paper and place in an air-tight jar or tin can until required. Whenever it is possible, the bandages should be freshly prepared before using them, as they set more quickly. If they have been kept for any length of time, place them in a hot oven for half an hour, when they will set as quickly as though freshly prepared. A little pulverized alum added to the water in which the bandages are wet will also help them to set more quickly. If gauze or cheese-cloth be used, it will be found very convenient to wind them over a round stick the width of the bandage, removing it be- fore the bandage is placed in the water. Plaster-of Paris bandages should never be wound by machine, as they are wound too tightly and the plaster is not apt to be so evenly distributed. Method of The plastcr-of- Paris dressing may be applied either by tion. covering the part to be inclosed by some loose fabric, and rubbing the moist plaster into it, or alternating the layers of the fabric with the moist plaster, until the de- sired thickness has been obtained, or by means of a continuous roller previously prepared. Sometimes a posterior or lateral splint is prepared from the plaster bandage and confined to the limb by spiral turns. First To apply a plaster dressing according to the first method, the part to be inclosed — the leg, for instance — should be first covered by a neatly applied flannel band- age, and bony prominences being padded to prevent undue pressure upon them ; the part is next covered by a layer or turn of crinoline, gauze, or cheese-cloth ; a small quantity of plaster-of-Paris, previously moistened FIXED DRESSINGS. 151 until it has the consistency of thick cream, is then smeared evenly over the entire surface of the previously applied bandage. Another layer of the material is then applied, to be in turn covered with* the moist plaster, until a dressing of the desired thickness is obtained. As in the first method, cover the part to be incased Second -^ method of With an evenly applied flannel bandage or a closely fitting amplication stocking, carefully protecting all the bony prominences with pads of cotton. Before applying, the bandage Fig. 73. — Leg Incased in Plaster-of-Paris Dressing. should be placed in sufficient warm water to entirely cover it, remaining without handling until the air- bubbles cease to escape — a sign that it is thoroughly soaked ; then squeeze out the excess of water and apply evenly and with just sufficient firmness to conform nicely to the part with as few reverses as possible. A sufficient number of bandages are applied to make the cast the desired thickness. When the last roller has been applied, the dressing is usually finished off with the plaster cream. 152 SURGICAL NURSING. Plaster cream. In preparing the moist plaster, use a small quantity of warm water, into which the plaster should be sifted gradually with the left hand, at the same time stirring it in one direction with the right, until it is as thick as rich cream ; then apply evenly with the palm of the hand. When a sufficient quantity has been applied, rinse the hand in warm water and smooth off the plaster by light downward strokes. When the plaster has thoroughly set, trim off the edges and bind with adhe- sive plaster. In applying these dressings narrow strips of tin, zinc, or binders' board are often incorporated in the dressing to give it additional support. In the third method pieces of plaster-of- Paris bandage are taken, sufficiently long and wide to reach from the knee to the middle of the dorsum of the foot and en- velop the malleolus. When the splint has been made the desired thickness, it is adjusted and held firmly in place by turns of a plaster bandage. Interrupted Where there is an open wound and it is still desired drSng. to employ a fixed dressing, an interrupted or fenestrated bandage is employed. If the wound be small, it may be covered by a pill-box, which can easily be cut out when the plaster has set, thus leaving the wound free. When the wound is larger, a short iron rod is placed under the limb some distance above and below the point at which the dressing is to be interrupted ; this is fixed by a few turns of a plaster bandage above and below that portion of the limb which is to be exposed ; stout wire is then bent into loops, the ends being incorporated Third method. Posterior plaster splint. FIXED DRESSINGS. 153 in the subsequent turns of the plaster bandage. Three loops are usually placed in addition to the iron bar, and will usually make the dressing sufficiently firm. A num- . Fig- 75-— Interrupted Plaster Dressing ber of turns of the bandage are applied to firmly fix the ends of the loops, and the leg is held in position until the plaster is firmly set. 154 SURGICAL NURSING. Bavarian In preparing the Bavarian dressing, take two pieces ot dressing. i- r o o' r flannel the length of the limb and once and a half the circumference of the same, sew them securely together through the middle; place under the limb and fit accurately by means of pins; then trim off". Remove the flannel and place upon a table. Prepare plaster-of- Paris cream and spread smoothly and thickly between the two pieces of flannel, then put together and place under the limb, taking care to have the seam in median line, bringing up the sides and molding the same accurately to the limb, where it is confined by a roller bandage. Whenever it is neces- sary to remove the dressing, the turns of the roller are cut, and upon separating the layers of flannel either or both halves may be turned aside, the seam at the back acting as a hinge. Upon replacing the splint it may be retained by an ordinary roller or a few turns of plaster bandage. Jackets constructed of plaster- of- Paris are largely employed in the treatment of spinal disease, and will be described in a subsequent chapter. To remove Plaster dressings may be removed by painting a line Paris dress- down the length of the dressing with hydrochloric acid or strong salt water, either of which softens the plaster so that it can be readily cut. Hydrochloric acid is objectionable because it ruins any instrument which may be used in the cutting. The most satisfactory way is to use a sharp knife or Hunter's saw. Dr. Wm. Barton Hopkins has devised a vertebrated metal chain which is wrapped in waxed paper Plaster jackets. FIXED DRESSINGS. 155 and applied to the part. It is removed when the dress- ing has firmly set, leaving a hollow ridge which can be easily cut through, first slipping a piece of sheet lead underneath. -ENTZaSONS Fig. 76. — Plaster Saw. Fig. 77. — Scissors for Removing Plaster-of-Paris. In applying this dressing starch is first mixed with starched cold water until a thick, creamy mixture is produced, when a sufficient quantity of boiling water is added to bandage. 156 SURGICAL NURSING. Gum and chalk bandage. Silicate ol sodium or potassium. Paraffin. make a clean, mucilaginous liquid. If too thin, it can be made thicker by boiling it a few minutes. The part to which the dressing is to be applied is first covered by a flannel roller, and over this a few layers of cheese-cloth or crinoline bandage, which has been pre- viously shrunken, are applied. The starch is then rubbed evenly into the meshes of the material, when another layer of bandage is applied. This is repeated until a dressing of the desired thick- ness is attained. This bandage is now seldom used, as it requires from twenty-four to thirty-six hours to harden. In this dressing equal parts of pulverized gum arabic and precipitated chalk are mixed with boiling water until it reaches the consistency of cream, when it is applied in the same manner as starch dressing. From five to six hours are required for it to harden. The silicate of sodium or potassium bandage may be applied by means of a brush upon the part, which should be previously covered with cheese-cloth or washed crinoline ; or the bandage may be dipped in solution and then applied. The former is by far the better way. These dressings are frequently employed in place of the plaster-of- Paris, when it is desired to remove the dressings frequently ; in which case they are arranged with hooks or eyelet holes and laced. In applying this dressing, paraffin, which melts at from 105° to 120° F., is employed. The limb is first covered with a flannel roller, when the vessel con- FIXED DRESSINGS. I57 taining the paraffin is placed in a basin of boiling water. As the cheese-cloth roller is unwound it is passed through the melted paraffin and applied to the part until a dressing of the desired thickness is obtained ; the surface is then brushed over with melted paraffin. This dressing sets rapidly, becoming quite firm in from five to ten minutes. CHAPTER XIV. SPLINTS AND BRACES. Use of Splints — Kinds and Mode of Application — Bran Bags — Sand Bags — Extension Apparatus — Fracture Box — Preparation for Dressing Fractures — Braces FOR Deformities. Use of Splints are employed to keep the fragments of bone in apposition in cases of fracture or dislocation, or where it is desired to keep the limb at rest. Kinds. The simplest splints are made of wood, but they may also be constructed from tin, gutta-percha, leather, felt, binders' board, wire, plaster-of-Paris, or soap plaster. Wooden Woodcn splints constructed from a smooth board of white pine, willow, or poplar, from ^ to ^ of an inch in thickness, may be used either straight or angular, and are easily prepared. Before applying any splint it should be well padded splint. ^ith cotton, oakum, or lint ; and in the straight splints the padding is usually held in place by a roller bandage. The straight splint is used in fractures or wounds of the hand, forearm, olecranon process of the ulna, leg, and patella; in the latter case it should be sufficiently long to reach from the upper third of the thigh to a point just above the tendo Achilles. 158 splints. Prepar; tioii of SPLINTS AND BRACES. 159 7 Fig. 78. — Straight Splint. { ^ L C.LENTZSfSONS o Fig. 79. — Internal Angular. Fig. 80. — Acute Internal Angular. Fig. 8i.— Obtuse Internal Angular. i6o SURGICAL NURSING. Fig. S2. — Anterior Angular. Fig. 83.— Stromeyer's Splint. Fig. 84.— Agnew's Metacarpal Splint. Fig. 8.S.— Straight Palmar. SPLINTS AND BRACES. i6i The angular splints are used in case of fracture or wound of the arm. Stromeyer's splint is employed for fracture or partial ankylosis of the elbow- or knee-joint, the limb being straightened by means of a screw. Agnew's metacarpal and the straight palmar splint AgneWs are used in fracture or wounds of the hand. metacarpal Bond's splint is used in Colles' fracture. The modepaimlr' of applying this splint varies, some surgeons using it^P^'"^^- well padded with small compresses upon the upper and Jp°Hnt'^ lower fragments of bone, while others use simply a double fold of lint and larger compresses. A substitute Fig. 86.— Bond's Splint. for Bond's splint may be prepared by fastening a roller bandage obliquely upon a straight wooden splint. Agnew's splint, which is provided with four pegs for AgneWs the attachment of strips of adhesive plaster, is used in Su/ed' cases of fracture of the patella, in place of the long, p^^^"^' straight splint used by some surgeons. A small com- press of lint is placed above the upper fragment, and another below the lower fragment. A strip of adhesive plaster, i}^ inches wide and 24 inches long, is then l62 SURGICAL NURSING. applied with its middle portion placed over the upper compress, the ends being brought obliquely downward and fastened to the lower pegs, the object of these Fig. 87.— Agnew's Splint for Fracture of the Patella. Fig. 88. — Hamilton's Splint for Fractured Patella. Strips being to bring the upper fragment in contact with the lower fragment. A similar strip of adhesive plaster with the ends pass- SPLINTS AND BRACES. 1 63 ing in the opposite direction is then placed upon the lower fragment and the ends fastened to the upper pegs. The lower strips serve only to steady the lower frag- ments. Two or three of these strips are sometimes ap- plied above and below where the screws are turned until the strips are sufficiently tightened. Sometimes the strips fit better when cut in the shape of a crescent. When the strips have been properly tightened, the splint is brought in firm contact with the limb by the application of a roller bandage. The limb is then placed upon an inclined plane or a long fracture box with its foot elevated, to relax the quadriceps femoris muscle. The foot of the bed should also be elevated to keep the patient from slipping down. This splint is made of wood accurately shaped to the Packard's outline of the back of the limb, and beveled at its upper knee'ex-'^ end. The part corresponding to the knee is cut out, ^*^^°"^- and the thigh and leg parts are securely fastened to a hoop on each side, a movable foot-piece serving to steadily support the foot. The knee part slides in and out, so that the dressing can be changed without mov- ing the limb. Leather strips with lacings are used to retain the limb in position ; or bandages or adhesive strips may be used. In this dressing for fracture of the shaft of the femur. Dr. Ash- the lateral support is given to the limb by the applica-drllsing tion of two wooden splints, the outer or long one ex- o°Mhe sS tending from the axilla to the ankle, the inner or short °^ ^^'""'■• one extending from the ankle to the groin. The splints should be about i64 SURGICAL NURSING. tremity, the outer one from five to six inches wide at the upper extremity, while the inner one should corre- spond at its upper extremity, with the width of the outer splint at the point opposite the groin. The splints are wrapped in a splint cloth made of a single width of canvas about three-quarters of a yard long, leaving a space in the center to correspond to the shape of the Fig. 89. — Packard's Splints for Knee Excisions. limb, and sufficiently wide to interpose bran-bags be- tween the splints and the limb. Or the cloth may be laid under the limb and the splints fixed in proper posi- tion. The outer bran-bag should reach from the ankle to the axilla, and the inner bag from the ankle to the groin. The entire dressing is made to conform closely to the limb, by three strips of bandage, one above and two below the knee, passed under and over the dressing, SPLINTS AND BRACES. i6S and securely tied, drawing the knots over the outer edge of the splint. A '* binder," composed of a double fold of muslin, is passed under and over the chest and long splint and securely pinned. A wad of oakum or cotton is then placed under the tendo Achilles to relieve the pressure, and the ordinary extension applied. This makes an exceedingly comfortable dressing and the patient is easily handled. Many surgeons prefer to use sand-bags in place of the long splints and bran-bags, in which case the bags are Fig. 90.— Long Splint for Fracture of Frmvr.—( Ashhttrsi.) almost filled with dry, white sand, leaving sufficient room to flatten the bag at its upper extremity. The bags are kept in accurate contact with the limb and body by means of the binder and strips of bandage. It is always best to protect the upper end of the inner bag, in either case, with a cap of oiled silk or muslin, to keep them fresh and clean. After the application of the dressing, the thigh should be slightly abducted and kept in that position, the inner malleus, outer tuberosity of the knee, and the great tro- chanter being in line with one another. 1 66 SURGICAL NURSING. Extension The extension apparatus is constructed by taking a apparatus. ^ . jo piece of adhesive plaster (the machine-spread plaster is to be preferred to the rubber) two inches wide and long enough to extend from the outer side of the thigh to three inches below the sole of the foot, and from this point back to the inner side of the knee. In the center of this strip is placed a block of wood about two inches wide and five inches in length for an adult, four inches for a child, with a perforation in its center; the block and the inner surface of the plaster are next faced with a similar strip to a point about one inch above the mal- leoli ; another strip of plaster is passed around the block to fix the previously applied strips. The strip of plas- ter is then warmed or wet with ether and applied to the sides of the limb and held in position by two circular strips of plaster, one above the malleoli and the other below the knee. A roller bandage is then applied to the foot and limb, and carried to the knee. Through the perforation in the center of the block or stirrup is fastened a cord, which passes over a pulley fastened to the foot of the bed or to an extension stand- ard, and to this cord is attached the extension weight. The foot of the bed should be elevated three or four ■ inches, by means of blocks, to make counter-extension. Before applying the extension shave the limb care- fully, to prevent pain when the plaster is removed. Prepara- The dressing for fracture of one or both bones in the tureboxforleg is usually best accomplished by means of a fracture frac"ure^. box, which cousists of a posterior splint with movable sides and a foot-piece. SPLINTS AND BRACES. 167 Fig. 91. — Extension Standard. i68 SURGICAL NURSING. It may be single, double, or double-inclined. In preparing the box for the reception of the limb, Fig, 96. Dr. Levis's Apparatus. the sides are lowered and a soft pillow, full enough to make equable pressure upon the limb when the sides of the box are adjusted, is placed smoothly in it ; two or SPLINTS AND BRACES. 169 three strips of bandage long enough to pass under and across the box are slipped under and tied loosely or crossed upon the pillow ; another strip of bandage Fig. 97. — Single Fracture Box. Fig. 9S.— Double-inclined Fracture Box. Fig 99. — D(;uBLE-i.NCLiNED Fracture Box. I 7© SURGICAL NURSING. sufficiently long to cross over the foot, the ends passing through the slits in the foot-piece and lied, is then ad- justed. A pad of oakum or cotton is placed under the tendo Achilles to relieve the heel from pressure ; another pad or folded towel is placed between the sole of the foot and the foot-piece, the foot being drawn firmly against the board, and at right angles with the limb, where it is securely tied ; the sides are then brought up and secured. In the subsequent care of the fracture, care should be taken to keep the foot well down to the foot-board, and at a right angle with the leg, and that there is no ever- sion of the knee. The patient should also be kept in the recumbent position. ^ Whenever a wet dressing is used about the limb, the pillow should be protected by a mackintosh pillow-case. Prepara- In preparing a fracture box for a compound fracture, tion for . . compound it IS a very good plan to arrange the dressing in a fresh fracture box, using a '^Scultetus" bandage made of broad strips of gauze, the strips being laid upon wax or parchment paper in such a'manner that it may be ap- plied from below up. If cotton be used, place the cot- ton, of proper size, upon the bandage, then the super- ficial and deep dressing ; fold the entire dressing from both sides to correspond to the width of the box. When the old dressing has been turned down and the limb is ready, simply change the box and adjust the dressing. If skilfully managed, it will cause very little disturb- ance to the limb and can be accomplished in half the time. In some cases where the patient becomes restless, SPLINTS AND BRACES. 171 the fracture box is swung from a frame fastened over the bed. The old-fashioned tin splints are now replaced by Lee's -,- , . . r metallic those constructed from a very light metal made of a splints. mixture of aluminum, copper, and bronze, nickel-plated and perforated to allow ventilation and the escape of Fig. 100.— Salter's F"hacture Cradle or S\v: the secretions. The splints are so accurately fitted that they require little padding. A slight roughness is left on the outside of the splints by the perforations, to pre- vent the bandage from slipping. The splints are de- signed for treatment of fracture of the arm, elbow-joint, phalanges, clavicle, maxilla, femur, patella, tibia, and 172 SURGICAL NURSING. fibula, and are the only splints made for infants under three years of age. Gutta- Splints made from sheets of oidta-percha, from J^- to Percba . ^ ,,.,., ^ . ^^ splints. y% of an inch in thickness, are sometimes used. The gutta-percha is prepared for use by immersing in hot water, when it becomes soft and can be readily molded to the surface of the body. Undressed Uudressed leather is also a good material from which splinrs^. to construct splints. It is softened by soaking in boil- ing water, then padded and molded to the part. It is often employed in making jackets for curvature of the spine. Russian Russian felt, made from wool saturated with gum felt splints. -^ ' ° shellac and pressed into sheets, is an excellent material for splints. It should be shaped as nearly as possible to the limb to which it is to be applied, then placed be- tween wet cloths and ironed with a hot iron until it is thoroughly softened. Before adjusting the splint, it is best to first apply a primary roller to the lijnb, then one splint confined by a roller, then the second splint, also held in position by a well-applied roller. In cutting the splints for a leg it is best to take the circumference of the limb below the knee and above the ankle, thus shap- ing the splint, allowing one inch between the margins of the felt, which should be beveled a little. When the fracture is in the middle third of the limb, the foot- piece is sometimes cut off. This gives an exceedingly light splint and is very comfortable to the patient. Binders' Binders' board may be used for the same purpose, and should first be immersed in hot water until it is SPLINTS AND BRACES. 173 sufficiently soft to be readily molded to the part ; it is then padded with raw cotton and applied by means of a roller bandage. Some special splints are constructed from wire, not- Wire ably Prof. Ashhurst's splint for resection of the knee, and Prof. N. R. Smith's anterior splint for fracture of splints. Fig. ioi.— Molded Splints of Felt or Binders' Board. the leg and thigh, by which the entire limb is swung, thus allowing the patient to move about in bed without disturbing the limb. The splint employed by Dr. Jno. Ashhurst, Jr., for Prof. jno. resection of the knee-joint, consists of a posterior wire fp^iinV'/or'^ splint with an adjustable foot-piece. The portion of knee." marked A A is composed of wire basket-work, and in 174 SURGICAL NURSING. Fig. 102.— Prof. N. R. Smith's Anterior Splint for Fracturfd Thigh. Fig. 1C7.— Dr. Ashiiikst's Splint for Rksection of Knek-joint. SPLINTS AND BRACES. 1 75 preparing the splint for use, is well padded with oakum covered with lint securely sewed ; this, in turn, is cov- ered with oiled silk. The foot-piece, B, is accurately adjusted and is then also padded with oakum covered with lint. The framework is then neatly covered with bandage or other material. The limb is placed in position, the knee filling the open space between the basket-work, the foot adjusted, and the splint held in position by means of adhesive strips. A ** Scultetus " bandage to fit the opening is arranged upon parchment paper, the dressing placed upon it, and the whole slipped under the limb and brought up in position through the curved bars. A roller bandage is then applied in such a manner that the dressing may be readily changed without disturbing the splint. The successive dressings are arranged in the same manner upon a ** Scultetus" and slipped into place. Soap-plaster for surgical purposes is prepared bySoap- spreading emplastrum saponis upon kid or chamois to a splints. thickness of ^ of an inch. It is frequently employed in the treatment of sprains, or in old fracture where it is necessary to give the limb some support. It is readily molded to the part and held in position by a roller bandage. It is also used over bony promi- nences before applying other splints, and may be applied to other parts of the body where pressure-sores are apt to occur. Plaster-of- Plaster-of- Paris may be employed in the construction splints. 176 SURGICAL NURSING. of splints, either movable or fixed. Its application has been previously described. dicai°aifpa- Jackets made of plaster-of- Paris are largely employed ratus. jn the treatment of spinal disease. Before applying the plaster, the body of the patient should be covered with a soft, close-fitting, woven shirt without sleeves, or sometimes stockinet or a flannel bandage is used. A pad consisting of several thicknesses, or a wad of cotton, is placed over the abdomen between the shirt and the skin, called the ''dinner pad," which is removed when the plaster has set, thus allowing space for the disten- tion of the abdomen after eating. Small pads of piano felt or raw cotton should also be placed over the anterior iliac spines. The patient is then suspended, either by Prof. Sayre's apparatus, or in a hammock made of cheese-cloth. Prof. Sayre's apparatus consists of a curved iron cross- beam, to which is attached an adjustable head and chin collar, with straps fitted to axillary bands. To a hook in the center is attached a compound pulley, the other end of which is secured either to a hook in the ceiling or to the top of an iron or wooden tripod about ten feet high. The head and chin collar and axillary straps are adjusted, and the patient is then slowly raised until only the toes touch the floor. This position is maintained by the aid of an assistant. The shirt should be well drawn * down over the hips and held in position until a few turns of the bandage have been applied. The turns of the bandage should be applied evenly and not too tightly, and are repeated until a dressing of the desired SPLINTS AND BRACES. 1 77 thickness is obtained, when the jacket may be finished off with the moist plaster, binding the edges with adhesive plaster. Sometimes strips of zinc or tin are Fig. 104.— Sayre's Suspension Apparatus. placed between the layers of the bandage, to give additional strength to the dressing. In disease of the spine involving the cervical or Jury-mast >> • 11- incorpor- upper dorsal vertebra the "jury-mast is employed in ated with connection with the plaster jacket. The apparatus con- jacket. 178 SURGICAL NURSING. sists of two bars of malleable iron bent to fit the curve of the back. Two or more roughened tin strips, long enough to go nearly around the body are attached to the lower por- FiG. 105.— Jlry-.mast and Head Support. tion. A central shaft, carried in a curve over the head and capable of being elongated at will, springs from between the two cross-pieces of the upper extremity of the iron pieces. To the upper extremity of this is attached a swivel SPLINTS AND BRACES. 179 cross-bar with hooks, from which depend straps support- ing the head and chin collar. After a few thicknesses of the plaster roller have been applied the ''jury-mast " is adjusted, care being taken that the malleable iron strips are bent to conform to the surface of the plaster, and that the shaft over the head be kept in line with the spinous processes. The perforated tins are carried around the body, but should not be allowed to meet. The apparatus having been thus adjusted, additional layers of plaster bandage are applied to hold the instrument firmly in place. Some surgeons employ a hammock made of cheese- Application cloth in place of Prof. Sayre's apparatus in applying a jacket by . . 1 -ij --m 1* means of a plaster jacket, when the patient is a child. 1 he ham- hammock. mock is made of two or three thicknesses of cheese- cloth swung from pulleys. The child is laid in the hammock, extension being made from the feet and shoulders ; the cheese-cloth is cut at the axilla and at the curve of the hip, and fitted closely to the body, the plaster bandages being applied over the cheese-cloth and finished in the usual manner. When the plaster has thoroughly set, the superfluous cheese-cloth is cut away and the child lifted down. Sometimes the jackets are made to lace up in front when it is thought desirable to remove it at night. Dr. T. W. Sloan, of Seattle, Washington, has devised Dr. t. w. Sloan's another method of employing the hammock. Instead method. of cutting it at the axilla and curve of the hip, it is made to conform to the body by means of gauze band- ages hung from a horizontal bar. Whenever the ham- i8o SURGICAL NURSING. mock is employed, a long table is usually placed under the patient, to prevent danger from falling. Fig. 106.— Dr. T. W. Sloan's Method. Fig. 107.— Spinal Jacket of Leather. Spinal brace. In many cases braces made of steel, leather, or alumi- num are employed in the treatment of spinal diseases, in SPLINTS AND BRACES. i8i preference to the plaster-of-Paris jackets, as they are lighter and cooler, and can be readily removed. When made of hardened sole-leather, a mold of the Leather. Fig. io8.— Spinal Jacket with Jury-mast. body is taken by means of the plaster-of-Paris jacket, over which the leather is accurately fitted. It can be made with or without the jury-mast. The steel brace made by Max Wocher & Son, of Cin- steel or cinnati, consists of a well-padded steel pelvic band, to ^^"""""'"' l82 SURGICAL NURSING. the posterior portion of which upright bars are fastened, shaped to conform to the curve of the spine. To these bars strong cloth or jean belts are attached, which en- circle the trunk and lace in front, and thus firmly adjust the apparatus to the body, at the same time sustaining WOCHtR & SON OIN O Fig. 109. Fig. Max VVocher's Spinal Brace. the lower part of the body (the abdomen) in an upright direction. Two adjustable crutches are attached later- ally which elevate the body by pressure mostly under the margin of the scapulae, and also remove the weight of the head and shoulders from the spine. The same brace may be made without the crutches and with pads, SPLINTS AND BRACES. 1 83 to correct the curvature. In applying these braces, the patient should be made to lie perfectly flat upon the back; the brace is then placed in position, being care- ful to have the pads in their proper position, then lace, and adjust the shoulder-straps, which should be made as tight as can be comfortably borne, so that the brace does not slip. If carefully adjusted, it remains in perfect position and is comfortable to the patient. Dr. Thomas' hip-splint consists of a pelvic band to Dr. .... ,, ., ^ , -,., Thomas' which is attached a posterior bar of steel covered with splint for leather and extending down over the buttock, fitting disease. closely against the leg to just above the ankle. There is a band around the thigh and one directly over the knee, and at the bottom above the ankle. A pelvic band of muslin is secured in front by means of straps and buckles, to hold the upper portion of the splint firmly in place. When this apparatus is firmly applied, there is no possibility of motion at the hip-joint in any position in which the patient may place himself. A cork-sole shoe 2^ inches high is worn on the well foot and crutches applied. Dr. Taylor's long hip-splint consists of a pelvic band P^- Tay- . o JT I- tr Iqj-'s brace. to which is attached a lateral bar extending from the crest of the ilium to sole of foot, ending in a foot-piece to which two perpendicular straps are attached. A second strap passes around the thigh. Counter-exten- sion is made by means of two perineal pads fastened to the pelvic band with straps and buckles. Before applying the brace the patient should be laid 1 84 SURGICAL NURSING. Fig. hi JOINT Apparatus. SPLINTS AND BRACES. i8s upon his back, and care should be taken that the pelvis is not inclined forward by contractions of the flexor muscles. Should this be the case, elevate the limb until the lumbar vertebra touches the bed and the spinal col- umn assumes its normal position. Then apply the splint. Two pieces of adhesive plaster terminating in a buckle are ap- plied to either side of the limb, the buckles coming about two inches above the malleoli. A few turns of a roller bandage are then applied around the ankle in such a manner as to protect the flesh under the buckles, and then continued up to the knee. The foot-piece is adjusted to the desired amount of extension and held in that position by means of the perpendicular straps. The perineal straps are so adjusted that the patient sits firmly and comfortably upon them. The foot is dressed with a shoe in the ordinary manner, and a cork-sole shoe is worn upon the sound limb. At first the pa- tient will be obliged to use crutches, but after learning to manage the brace, walks easily without. This brace may be worn at night,thus keeping up constant extension. 13 Fig. 112.— Taylor Brace, CHAPTER XV. MASSAGE. Definition. Massagc is the systematic and scientific method of improving the nutrition of different parts of the body by means of rubbing and kneading upon the nude skin. It is particularly useful when the circulation is im- paired and when it is desired to promote flexibility in the muscles. Divisions. Dr. Mczger divides the treatment into four different manipulations : 1. Effleurage. 3. Petrissage. 2. Frictions. 4. Tapotement. Emfurage. Efflcurage consists of centripetal (toward the head) strokings, and is performed in four different ways: Stroking with the palm of one or both hands. Stroking with the thumb. Stroking with the tips of the fingers. Stroking with one hand is used upon the extremities, in single massage of the neck and the back of the head. Stroking with both hands is used upon the lower ex- tremities in adults, in double massage of the neck, and also upon the chest and back. Stroking with the thumb is used between two muscles, or between a muscle and a tendon. 186 MASSAGE. 187 Stroking with the tips of the fingers is principally used around the joints after sprains, etc. The aim of all strokings is to increase the circulation of the venous blood-vessels and lymphatics, thus caus- ing absorption. Frictions are firm circular movements always fol- Frictions. lowed by centripetal strokings ; they are usually per- formed over one group of muscles at a time, and are given in three different ways : Friction with the thumb. Friction with one hand. Friction with the tips of the fingers. Friction with the thumb is used upon the[extremities, also around the knee-joint, and upon the facial muscles. Friction with one hand is used upon the larger sur- faces and the fleshier parts — for instance, the thigh, arm, and lumbar region. All frictions should be centripetal and followed by centripetal strokings. The aim of this manipulation is to transform pathologically changed parts into such a condition that they may be incorporated into the healthy tissues, and so be absorbed by the veins and lymphatics. Petrissage, or kneading, is performed in such a manner petrissage as to cause a double centripetal pressure upon a muscle Tng."^^ or tendon, at the same time raising it from its point of attachment, and is performed in three different ways : Kneading with both thumbs. Kneading with thumb and fingers. Kneading with both hands. l88 SURGICAL NURSING. Kneading with both thumbs is used to reach the sep- arate muscles. Kneading with the thumb and fingers, called pinch- ing, is preferred on a deep-seated tissue, and is also employed to reach individual muscles. Kneading with both hands, or squeezing, is used upon the arm proper and the lower extremities of adults. The aim of kneading is to reach the individual mus- cles with a firm double pressure, and subject them to an action similar to that of friction. Tapote- Tapotement, or percussion, is always performed from percussion, the operator's wrist, the hands striking quickly, and is performed in four different ways : 1. Clapping, performed with the palm of the hands, acting upon the skin and the superficial nerves and vessels. 2. Hacking, performed with the ulnar border of the hand, used around the nerve-centers and upon the muscles. 3. Punctation, performed with the tips of the fingers, used upon the head and in circles around the heart. 4. Beating is performed with the clenched hand, and is used upon the lower extremities over the sciatic nerve and upon the glutei. Requisites I^ ordcr to give massage successfully the nurse must masseur, have a good physique, gentle touch, pliable skin, be perfectly strong and healthy, with well-developed mus- cles. She should be attired in a loose dress and be scrupulously clean. The operator should have a good general knowledge MASSAGE. 189 of anatomy, and must bear in mind the direction of veins and lymphatics, which, in the lower extremity, converge toward the groin and in the upper extremities toward the armpits^ or axilla. The patient should lie upon a moderately firm bed, Prepara- and be covered with a blanket. Or a more convenient patient. and comfortable covering may be made by using a piece of white flannel, twice the length of the patient, fold- ing it lengthwise ; cut a hole in the fold through which the head may be passed, allowing the arms to remain outside ; the edges may be fastened together with safety- pins. In- giving general massage the following order is order of usually observed: ^^'''"^• 1. Toes and foot. 2. Leg and knee. 3. Thigh. 4. Arms. 5. Chest. 6. Abdomen. 7. Back. It will be found more convenient to begin with the left foot and leg, then have the patient turn over on the other side of the bed, where the rest of the treatment may be easily given. Great care should be taken that the patient is not exposed in any way during or immediately after the treatment, as after a little rubbing the temperature will begin to rise and the patient will readily take cold. Massage should never be given when the skin is SoS'fo'l-'" massage. 190 SURGICAL NURSING. abraded or bruised ; hence should not be employed in skin affections, in tumors or purulent inflammations, diseases of the kidneys, in acute disease of the bone- tissue, pregnancy, or in any case where the pressure is liable to cause a hemorrhage. Indications It is beneficial in spinal disease, paralysis, constipa- for mas- . . , , ^ 1 • , sage. tion, m club- foot, and m the after-treatment of fractures and sprains. Massage may be given to the entire body in from thirty to thirty-five minutes; but the first seance should not last over twenty minutes. Be very gentle at first and do not tire the patient. Use the utmost care in giving massage after a fracture. In all sprains use friction, kneading, rolling, and light percussion. Lateral curvature of the spine is due to weakness of the muscles on one side. The muscles on both sides of the spine are reached by friction. To learn massage thoroughly requires a. systematic course of instruction, and considerable practice. APPENDIX A. INVALID COOKERY. Barley Water — Imperial Drink — White Wine Whey — Egg- and-Brandy Mixture — Egg Flip — Flaxseed Tea — Beef Tea — Beef Tea and Egg — Chicken Tea — Clam Bouil- lon— Lemon Jelly — Beef Juice — Snow' Pudding. Wash thoroughly two ounces of pearl barley, and place Barley in a saucepan with two quarts of water. Boil for two hours or more until the barley is quite soft, stirring and skimming occasionally. Strain through muslin and sweeten to taste. If allowable, a little lemon juice may be added, which improves the taste. Place a dessertspoonful of cream of tartar and two imperial tablespoonfuls of powdered sugar in a jug. Pare the rind of a lemon very thin, and, cutting it into little slices, place them in the jug. Pour one quart of boil- ing water over it, cover, and allow it to stand until it is cold, then strain it. (" Manual of Nursing," Hum- phry.) To half a pint of boiling milk add one or two wine- white wine glassfuls of sherry; strain through a fine sieve, sweeten ^^ '^^' to taste with sifted sugar, and serve. Beat up three eggs to a froth in four ounces of cold Egg and water, and then add four ounces of brandy. Mix well, mixture. 19T 192 SURGICAL NURSING. and sweeten to taste. A little nutmeg may be added. Give a tablespoonful or so at a time, as directed. Egg flip. Beat an ounce of powdered sugar and the yolks of two eggs together, adding eight tablespoonfuls of brandy and eight tablespoonfuls of cinnamon water previously mixed together. Flaxseed Take One ounce of white sugar and the same quantity of whole flaxseed, adding four tablespoonfuls of lemon juice. Place in a jug and pour over it one quart of boil- ing water. Allow the mixture to stand in a warm place four hours. Then strain and use. This drink should not be given to patients who are taking iron, lead, or copper as medicines. Beef tea. Cut One pouud of lean beef into small pieces; put it into a covered jar with one pint of cold water and a little salt. Allow it to simmer for a couple of hours, but do not let it reach the boiling point until two or three minutes before taking it from the fire. Beef tea Beat the white of an egg to a light froth, and add to egg. .^^ ^^^^^ gradually, a teacupful of beef or chicken tea, which must be hot, but not boiling. Chicken Take a small chicken, free it from skin and from all fat between the muscles ; and, dividing it lengthwise, re- move the whole of the lungs, liver, and everything adhering to the back and side bones. Then cut it, bones and muscles, with a strong, sharp knife, into as thin slices as possible; place in a sauce- pan with a sufficient quantity of salt, and pour over it tea. INVALID COOKERY. 193 one quart of boiling water. Cover the pan and sinamer with a slow lEire for two hours. Allow it to stand for half an hour, then strain through a sieve. Take three large clams and allow them to stand in ciam boiling water until the shells begin to open. Drain out the liquor, add an equal quantity of boiling water, a teaspoonful of finely pulverized cracker crumbs, a little butter, and salt to taste. One box of gelatin, juice of four lemons and rind of Lemon three. Pour over this one quart of cold water and let it stand four hours, then add one quart boiling water and i^ pounds of granulated sugar. If wine be used, one pint of water. Strain through a fine sieve, turn into a mold, and set on ice or in a cold place. Place half a pound of lean, juicy meat upon a broiler Beef.jui,,. over a clear, hot fire, and heat it through. Press out the juice with a lemon-squeezer into a hot teacup. Add salt to taste. Dissolve one-half box of Cox gelatin in one pint of Snow .... A ^ 1 r- 1 • t 1 pudding. boiling water. Add two cups of white sugar and the juice of one lemon. When it begins to thicken, add the whites of three eggs thoroughly beaten. Sauce. — Boil one pint of milk and add the yolks of three eggs, one tablespoonful of corn-starch, half a cup of white sugar. APPENDIX B. Nutrient Enema. — Ice Poultice. — Excessive Perspiration. — Tables of Weights and Measures. — Bichlorid Table. — Poisons. Nutrient enema. Ice poul- tice. Excessive perspira- tion. Three ounces of strong beef tea, the yolk of one egg, and an ounce of brandy. Given at a temperature of 90° to 100° F. Inject slowly directly after a natural movement, or about an hour after the bowels have been washed out with a simple enema. Take a fold of gutta-percha tissue a little larger than the area to be covered. Sprinkle a thin layer of ground flaxseed upon the lower leaf, and upon that crushed ice to the depth of half an inch ; sprinkle the ice with salt, and upon that another layer of flaxseed. Turn the upper leaf over the lower one and seal the edges with chloroform or turpentine ; put the poultice into a flannel bag, and place under it a layer of lint. (" Guy's Pharm.") Keep all the. functions of the body in healthy condi- tion, and when suffering from the trouble in axillae avoid as much as possible the use of rubber dress shields; bathe frequently and apply dusting powder composed of equal parts of pulv. boric acid and Lubin's toilet pow- der. If, notwithstanding extreme cleanliness and the T94 DRY AND FLUID MEASURES. 195 use of the powder, the condition does not improve, use diluted ammonia or alum and camphor water : Alum,* gr. xl Aqua camphora, f^viij. Wash axillae, dry. thoroughly, and apply by means of absorbent cotton. DRY MEASURE, gr. j Signifies one grain. gss 3J I] R,j Weights, one scruple = 20 grains, half a dram = 30 grains, one dram = 60 grains, half an ounce =: 4 drams, one ounce = 8 drams. one pound =16 ounces. ITIJ Sign f5J ' f^iJ f^ss '' Oj FLUID MEASURE, fies one minim (about one drop). one fluidram =: 60 minims = one teaspoonful. two fluidrams = one small dessertspoonful, half a fluidounce = one small tablespoonful. one fluidounce = two small tablespoonfuls. one pint = 16 fluidounces. Measures. * Lecture delivered by Dr. Neilson. 196 SURGICAL NURSING. BICHLORID TABLE.* To make one pint of a Take of the solution Equivalent to below- solution the strength i containing fifteen j stated amount of bi- of : j grains in one fluid- chlorid of mercury : ounce: I in 500, .... I fluidounce 15 grains. I in 1,000, 4 fluidrams 7>2 (< I m 1,500, • • • 3 " 5 '< I in 2,000, 2 " 3}{ " I in 4,000, 60 minims 1% t« I in 5,000, 48 " 1% << I in 6,000, 40 iX n I in 8, 000, 30 " if gram. I in 10,000, 24 " 'A " I in 12,000, 20 i ( 'A (( I in 15,000, ... 16 " 72 << Poisons and antidotes. POISONS. Poisons. Acetate of lead. Acid, acetic, hydrochloric, nitric, sulphuric, tartaric. Acid, carbolic. Acid, oxalic. Antidotes. Emetics and stomach pump : sul- phate magnesia, or phosphates of soda and magnesia. Magnesia, chalk, wall-plaster, lime- water, whiting, soap-water, milk, oil, demulcents. Raw eggs, olive oil, powdered chalk, milk, demulcents, emetics. Chalk, common whiting, or magne- sia suspended in water, emetics. ■* Pennsylvania Hospital. POISONS. 197 Poisons. ammonia, potash, Aconite. Alcohol. Alkalies, soda. Arsenic. Atropin, belladonna, hyos- cyamus. Caustic, lunar. Chloroform, chloral, amyl nitrite, ether. Corrosive sublimate (or other preparation of mercury). Digitalis. Iodoform or iodin. Irritant Gases — Carbonic acid, chlorine, nitric acid, hydrochloric acid. Lead, sugar of. Antidotes. Emetics of sulphate of zinc, stomach pump, stimulants, as brandy, 'am- monia, strong coffee. Stomach pump, emetics, cold affu- sion, carbonate of ammonia. Weak acids, as vinegar, lemon- juice or citric acid, and water, followed by olive oil in large quantities. Milk, raw e^gs, sweet oil, lime- water, flour and water. Stomach pump, emetic of sulphate of zinc, ammonia and stimulants, tannin, opiates. Salt, white of egg or milk. Fresh air, cold affusion, ammonia to the nostrils, artificial respira- tion, counter-irritants, cathartics. White of eggs, flour in milk or water, emetics. Stomach pump, emetics, tannin, stimulants, cathartics, recumbent position. Stomach pump, demulcent drinks. Pure air, inhalation of ammonia, ether, or vapor of warm water, artificial respiration. Emetics, Epsom salts. 198 SURGICAL NURSING. Poisons. Morphin, opium, opium prep- arations, chloral hydrate. Phosphorus (in phosphorus paste or rat-poison). Prussic acid. Strychnin or nux vomica. Antidotes. The stomach pump, emetic of sul- phate of zinc, external stimula- tion, exertion. Large quantities of water, lime- water; no oils. Fresh air, cold affusion, smelling salts, brandy. An emetic or stomach pump, large doses of chloral, inhalations of ether. APPENDIX C. To prepare a patient for transfusion, thoroughly ^^^ ^^ cleanse the inner surface of the arm above the elbow, ^ p^^^^"^ ' for trans- by scrubbing with a nail-brush and green soap, followed ^"^'°"- by the use of sterile water, alcohol, bichlorid solution I : I GOG, and ether. The articles used in giving a transfusion are : One sharp scalpel. One cannula (small). Three artery clamps. Two pairs mouth tooth forceps. One aneurysm needle. One surgical needle (straight). One pair of dressing scissors. Black silk ligature. Catgut, rubber tubing. Glass funnel, dressing rubber. Sterile dressing, bandage, pins. Esmarch bandage (small). Normal salt solution, from Oj to Oij, 115° F. Normal salt solution contains approximately the same formal amount of salt as is found in the blood serum — /. e., e saitsoiu- ' 1 0 tion. of one per cent. U. Sodium chlorid, 6 gm. (circa ^iss) Distilled water, I liter (circa Oij). 199 200 SURGICAL NURSING. The salt should be thoroughly dissolved in the water by stirring with a glass rod. It is then filtered through filter-paper into a sterile flask or bottle of a capacity of about Oij. Close the flask or bottle with absorbent cotton, keeping the plug in position by a few turns of a gauze bandage, to prevent an accumulation of dust upon the lips of the bottle. The solution is allowed to boil by holding the flask over a Bunsen burner or gas flame, and is then placed in a sterilizer and steamed for half an hour. This process is repeated three times, at intervals of twenty-four hours. The solution quickly decomposes, and should be kept perfectly clear. To prepare Wash the tissue thoroughly with green soap, and after tissue. rinsing it with sterile water, place it in a solution of bichlorid i : looo, for one hour; then remove it and dry it thoroughly with a sterile towel or gauze and keep it in normal salt solution or in a closely sealed glass jar. Kronig's i. Cut the catgut into desired lengths, and roll of steriiiz- twelve strands into a figure-of-eight, so that it may be ing catgut. ,. , . , ■ ^ ^ *= slipped into a large test-tube. 2. Bring the catgut gradually up to a temperature of 80° C. in a hot-air oven, and hold it at this point for one hour. 3. Place the catgut in cumol ; surround the tube with a sand-bath; raise the temperature to 165° and maintain it at this point for one hour. 4. Pour off the cumol, and either allow the heat of the sand-bath to dry the catgut, or transfer it to a hot- PREPARATION OF CATGUT. 201 air oven, heated to a temperature of ioo°, until all the cumol is driven off. 5. Transfer the catgut with sterile forceps to test- tubes which have been previously sterilized, and close the opening with sterile cotton. 14 INDEX ABDOMINAL surgery, 107 Abrasion of skin, 6i Abscess, 86 Acupressure pins, 72 Agnew's splint for fractured patella, 161 metacarpal, 160, 161 Alimentary canal, 21 Amputations, 128 Anesthetic, diet before, 34 Aneurysm needle, 72 Antiseptic dressings, 38 Antiseptics, 25 Appendicitis, 113 Applicator, 50 Arteries, 6+ brachial, 64 radial, 64 subclavian, 64 ulnar, 65 Artery, axillary, 64 femoral, 65 temporal, 64 tibial, 65 Asepsis, 22 Ashhurst's dressing for fractured fe- mur, 163 splint for resection of knee-joint. Attitude, 21 Bandage, 37 Bandages, abdominal no Barton's, 139 circular, 135 compound, 139 cord, 143 cravat, 143 applied to axilla, 143 eight-tailed, 140 figure-of eight, 138,139 Bandages, four-tailed, 140 gum and chalk, 156 handkerchief, 141 hip, 126 Liebreich's eye, 145 many-tailed, no, 140 materials used for, 130 oblique, 135 paraffin, 156 plaster-of- Paris, 149 Pott's, 146 recurrent, 139 removal of, 134 roller, 133 Scultetus, no, 146 silicate of potassium, 156 of sodium, 156 spica, 137 spiral, 135 reversed, 135 starched, 155 T-, 139 triangle, 141 applications, 143 use of, 130 varieties of, 131 Bandaging, 130 dimensions in, 131 materials, 130 Bavarian dressing, 154 Bed-making, 10 for operation, 12 Bed-sores, 12 Benzoinated collodion, 28 Bichloridof mercury, 26 table, 196 Binders' board, 172 Blank for clinical memoranda, 16 Blood, composition of, 63 Bond's splint, i6i Boric acid, 27 Boro-salicylic, 27 203 204 INDEX. Box for compound fracture, 170 simple fracture, 166 Burns and scalds, 92 Carbolic acid, 27 Care of patient, 9 after gynecologic operation, 58 Catheters, 53 kinds of, 54 Cautery, Paqueliii's, 73 Cellulitis, 87 Cheyne-Stokes breathing, 19 Circulation, 62 Cleaning of drainage-tube, 108 Clinical chart, 16 Clothing of patient, 34 Colles' fracture, loi Compress in hemorrhage, 68 Concussion of the brain, 116 Corrosive sublimate, 26 Cough, 20 Cradle, 128 Curets, 51 Decubitus, 20 Diet before anesthetic, 34 Digital pressure in hemorrhage, 67 Dislocation, 104 definition, 104 of hip, 105 of jaw, 105 of shoulder, 105 symptoms, 104 treatment, 105 Drainage-tube, 36 tubes, 44 Dressing, 37 alcohol, 40 Bavarian, 154 emergency, 39 evaporating, 40 fixed, 149 for stump, 129 paraffin, 156 plaster, 149 removal of, 154 Duties of nurse toward physicians, 15 Epistaxis, 76 Erysipelas, 88 Esmarch's hard rubber compress, 70 rubber bandages, 69 tubing, 70 Examination, preparation of patient, 45 Excessive perspiration, 196 Excretions, 20 Expression, 18 Extension apparatus, 165 Feeding helpless patients, 13 Fixed dressings, 149 Flushing, 17 Forceps, cervix, 51 hemostatic, 71 Liston's, 71 speculum, 49 volsella, 51 Formal, 27 Fracture and dislocation, 97 Barton's, loi definition and cause of, 95 of clavicle, 99 Colles', loi of femur, 103 of patella, 103 of pelvis, 102 Pott's, 104 of radius and ulna, 100 of the ribs, 102 of shaft of humerus, 100 of skull, 98 of spine, 102 symptoms of, 96 of tibia and fibula, 104 treatment of simple, 97 Fractures, 94 compound, 96 kinds, 95 signs, 96 treatment, 94 Gauze, 38 borated, 38 iodoform, 39 plain, 39 Gonorrhea, 61 Gut, Kosher, 42 silk-worm, 43 Gutta-percha splints, 172 Gynecologic nursing, 45 Hamilton's splint, 162 Hammock in application of jacket, 179 Harelip pins, 72 Healing, 23 Hemoptysis, 78 INDEX. 205 Hemorrhage, 62 definition, 66 digital pressure in, 67 from bowels, 79 from rectum, 80 from stomach, 79 kinds, 66, 76 position after, 75 stimulants after, 75 thirst after, 76 treatment after, 75 vicarious, 79 Hemostatic forceps, 71 Herniotomy, 115 Hip bandage, 126 applied, 127 brace, 183 Taylor's, 183 Thomas', 183 disease, 125 frame for, 125 Ice poultice, 195 Injection, medicated, 58 preparation for, 58 Injections, 57 position of patient, 58 quantity and syringe, 57 temperature of, 57 Instruments, 35 sterihzation of, 55 to avoid hemorrhage, 68 Invalid cookery, 191 Iodoform, 28 in glycerin, 28 Irrigation, 35 of bladder, 113 Jury-mast and plaster jacket, 177 Kosher gut, 42 Lacerated perineum, 115 Leather splints, 172 Leis' metallic splints, 171 Ligatures, 35, 41 Liston's forceps, 71 Lithotomy, 113 Lithotrity, 113 Lividity, 18 Lymphatics, inflamed, 89 Massage, 186 Micro-organisms, 24 Nutrient enema, 194 Operating pad, 29 room, duties of nurse in, 30 preparation of, 28 Orthopedic apparatus, 176 Ovariotomy, 112 Packard's splint, 163 Packing, 36 Pain, 18 Paquelin's cautery, 73 Patient, preparation of, 32 Peroxid of hydrogen, 27 Petit's tourniquet, 68 Plaster-of-Paris splints, 175 Plugging posterior nares, 77 Poisons, 196 Position in gynecologic operations, 58 knee-chest, 46 Sims', 46 Preparation for examination, 45 of patient, 32 Protective agent, 43 Pulse, 19 Pyemia, 89 Respiration, ig Rubber bandage, 69 Russian splints, 172 Sayre's apparatus, 176 Scissors, cervix, 51 Kuechenmeister's, 52 Secretions, 20 Septic intoxication, 25 Shock, treatment of, 85 Sloan's method, 179 Smith's splint for fractured thigh, 174 Soap plaster splints, 175 Sound, 50 Spanish windlass, 68 Speculum, Cusco's, 49 Goodell's, 47 Fergusson's, 47 forceps, 49 Sims', 48 Robb's modification, 48 Spinal brace, 180 aluminum, 181 leather, 181 steel, 181 Wocher's, 182 2o6 INDEX. Splints, kinds, 158 preparation of, 158 wooden, 158 Sponge tents, 53 Sponges, 35, 40 mode of preparing, 40 Sprains, 105 Sputa, 20 Stomach, hemorrhage from, 79 Suppositories, 53 Suppuration, 25 Sutures, 36 Symptoms to be noted, 17 Syncope, 67 Syphilis, 60 Tampons, 52 Taylor's hip brace, 183 Temperature, 19 Tenacula, 50 Tetanus, 89 Thomas' hip brace, 183 Tourniquet, Petit's, 68 Towels, 30 Tracheotomy, 117 feeding after, 122 Tracheotomy instruments, 119, Trephining, 116 Ulcers, 90 Urine, 21 Uterine syringe, 109 Venereal disease, 60 Ventilation, 13 Weights and measures, 195 Wire splints, 173 Wounds and their complications, 8r of abdomen, 85 of chest, 85 complications of, 86 contused and lacerated, 82 diflTerent kinds of, 81 incised, 81 irrigation of, 83 management and dressing of, 82 of neck, 84 poisoned, 88 of scalp, 84 of the trunk, 85 Catalogue No. 5. may, 1899. BOOKS fOR- NURSES. FOR NURSES AND ALL ENGAGED IN ATTENDANCE UPON THE SICK. OR THE CARE OF CHILDREN. Dealing exclusively in books on medicine and collateral subjects, we are able to give special attention to supplying books for nurses. We have a large stock of works on Nursing, Hygiene, Popular Medicine, etc.. Temperature Charts, etc. Catalogues of Books on Medicine, Dentistry, Pharmacy, Chemistry, etc., free, upon application. Special attention given to orders to be forwarded to a distance, by mail or express. Upon receipt of the price, any book will be delivered, free, to any address. Money should be forwarded by Post- Office Order, Draft, or Registered Letter. P. Blakiston's Son & Co., I0I2 WALNUT STREET. PHILADELPHIA. 4®=" The prices as given in this catalogue are net. No discount can be allowed retail purchasers* A HANDBOOK OF MATERIA MEDICA Including: Sections on Therapeutics and Toxicolo§:y, and a very complete Glossary of Terms with Dose and use of each Drug:. SPECIALLY PREPARED FOR TRAINED NURSES. BY JOHN E. GROFF, Ph.G., Apothecary in the Rhode Island Hospital, Proz'idence. 235 PAGES. 12M0. HANDSOMELY BOUND IN CLOTH, $1.25. *^* In preparing this work the author has endeavored to present the extensive subject of Materia Medica in a systematic form, suffi- ciently comprehensive to meet the requirements of the trained nurse. The work is intended to make the nurse acquainted with the numerous drugs of vegetable and chemic origin, their Latin and English names, the parts of the plants used, the names of and some- thing about the preparations, the chemicals used as medicines, the handling of them, etc. A set of questions follow each chapter, and there are many explanatory foot-notes and paragraphs. From the Medical Record, New York. •' It will undoubtedly prove a valuable aid to the nurse in securing a knowl- edge of drugs and their uses." From Philadelphia Medical Journal. " The task of abridging the subject of materia medica for the use of trained nurses is far from an easy one, as it is necessary to use good judgment in putting in what it would be well and helpful for her to know without leaving out the necessary part. Moreover, to arrange the subject in a practical and sys- tematic manner for the purpose of teaching and ready reference is a difficult matter. The author of this book has succeeded admirably in doing this, and the work is sure to be in great demand by nurses." HUMPHREY'S MANUAL OF NURSING MEDICAL AND SURGICAL. A complete Text-Book for Nurses, including General Anatomy and Physiology, Management of the Sick-Room, Appliances used in Sick-Room, Antiseptic Treatment, Bandaging, Cooking for Invalids, etc., etc. Sixteenth Edition. With 79 Illustrations. BY LAWRENCE HUMPHREY, M.A., M.D. 12M0. CLOTH. PRICE $1.00. St. Joseph's Hospital, Seventeenth and Girard Avenue, Philadelphia, March 15, 1893. Messrs. P. Blakiston, Son <&* Co. :— Please send us six more copies of Manual of Nursing, by Humphrey. We do not know of any book that more completely meets the requirements of a Training Class than Dr. Humphrey's able Lectures, for they are at once clear, concise, and thoroughly practical. Sisters of Charity. From British Medical Journal, London. " Nursing literature is expanding, and, what is more to the purpose, it shows manifold signs of improvement with its growth. In the fullest sense. Dr. Humphrey's book is a distinct advance on all previous manuals. It is, in point of fact, a concise treatise on medicine and surgery for the beginner, incorporat- ing with the text the management of childbed and the hygiene of the sick-room. Its value is greatly enhanced by copious wood-cuts and diagrams of the bones and internal organs, by many illustrations of the art of bandaging, by tempera- ture charts indicative of the course of some of the most characteristic diseases, and by a goodly array of sick-room appliances, with which every nurse should endeavor to become acquainted The systematic arrangement jf subjects adopted by the author is excellent." THE BEST GENERAL TEXT-BOOK. NURSING IN ABDOMINAL SURGERY AND DISEASES OF WOMEN. A Series of Lectures Delivered to the Pupils of the Training School for Nurses Connected with the Woman's Hospital of Philadelphia, comprising their Regular Course of Instruction on such Topics. BY ANNA M. FULLERTON, M.D., Physician-in-Charge of and Obstetrician and Gyntecologist to the Woman' i Hospital o/ Philadelphia, etc. SECOND EDITION, REVISED. 12mo. 300 Pages. 70 Illustrations. Cloth, $1.50. *^*The immediate success of Dr. Fullerton's "Handbook of Obstetric Nursing," a fourth edition of which has just been pub- lished, has encouraged her to prepare this manual on another and very important branch of the science and art of nursing. Dr. Fullerton has demonstrated that she not only knows what to say, but that she has the happy faculty of saying it in a plain, practical . style that interests as well as instructs. Synopsis of Contents. — The Surgical Nurse — The Germ Theory of Disease — Asepsis and Antisepsis — Abdominal Section — The Pre- paration of the Room — The Preparation of Sponges — Sterilization of Instruments, etc. — Preparation of the Patient — Preparation of Operator and Assistants — The Nurse's Duties During Operation — The Nurse's Duties After Operation and During Convalescence — Management of Complications — The Pelvic Organs in Women — Diseases of Women— General Nursing in Pelvic Diseases — Pre- parations for Gynaecological Examinations — Preparation for Gynae- cological Operations - Preparation of Patient, Operator and Assist- ants— Duties of Nurse During Operation — Special Nursing in Gynaecological Operations — Diet for the Sick — Supporting Treat- ment of Abdominal Sections — Index. A HANDBOOK OBSTETRIC NURSING. Comprising the Course of Instruction in Obstetric Nursing given to the Pupils of the Training School for Nurses connected with the Woman's Hospital of Philadelphia. BY ANNA M. FULLERTON. M.D., Detuonstrator of Obstetrics in the Wovran's Medical College of Pennsyl- vania; Jhys citn-i7i-Charge and Obstetrician and Gynecologist to the IVoman's Hospital of Philadelphia, and Superintendent of the Nurse Trauiing School of the Woman' s Hospital of Philadelphia. 41 Illustrations. 12nio. Handsome Cloth, $1.00. FIFTH EDITION-REVISED. 262 PAGES. JUST READY. Synopsis of Contexts. — The Pelvis and Genital Organs — Signs of Pregnancy — Management of Pregnancy — Accidents of Pregnancy — Germs and Antisepsis — Application of Antisepsis to Confinement Nursing — Preparations for the Labor — Signs of Approaching Labor and the Process of Labor — Duties of the Nurse during Labor — Accidents and Emergencies of Labor — Care of the New-born Infant — Management of the Lying-in — Characteristics of Infancy in Health and Disease — The Ailments of Early Infancy — Index. " It is a book that I have recommended since I first saw it, and we are using It for our nurses at the N. Y. Infirmary, where we have a branch of our School, our nurses going there for instruction in obstetrics." — Mrs. L. W. Quintard, Supt. Connecticut Trainijig School for Nurses, New Haven, Conn. " It is the most modern and complete book I have ever read for the care of obstetrical patients. I shall take pleasure in recommending it to this school for study." — E. L. Warr, Supt. Training School for Nurses, City Hospital, St. Louis, Mo. " I have looked it over and read it with care, and think it is the best book I have ever seen on the subject. It is practical, with plain instructions, nothing superfluous. A good book for nurses and teachers of nurses." — Miss Anna G. Clement. Supt. of Nurses. The Henry W. Bishop Memorial Training School for Nurses, Pittsfield, Mass. " I consider the book excellent in every particular. Would recommend it to every nurse, whether she did obstetrical nursing or not " — Gertrude Mont- fort, Su/>t of Nurses, New England Hospital for Women and Children^ Boston, Mass. " What is to be learned in a maternity training school is the way to nurse as a profession. * * * Can recommend it as a valuable manual." — From theAmer* ican Journal of Medical Sciences. BOOKS ON NURSING. , SHAWE. Notes for Visiting Nurses, and all those Interested in the Working and Organization of District, Visiting, or Parochial Nurse Societies. By Rosalind Gillette Shawe, District Nurse for the Brooklyn Red Cross Society. With an Appendix explaining the Organization and Workings of various Visiting and District Nurse Societies, by Helen C. Jenks, of Philadelphia. i2mo. Cloth, ;^i.oo "A sensibly written, useful little manual is the ' Notes for Visiting Nurses,' by Rosalind Gillette Shawe, a district nurse for the Red Cross Society in Brooic- lyn. Compact, concise, practical, the advice in every detail is most excelleiit. The book is written for two classes of readers— the district nurse, who is in need of timely cautions and hints, and for those who would willingly uphold the hands of the workers did they but understand what the work really is, A valuable appendix gives information concerning the organization of societies for district nursing, and brief de-icriptions ol those already in operation." — The Christian Advocate, New York. CULLINGWORTH. A Manual of Nursing, Medical and Surgical. By Charles J. Cul- LiNGWORTH, M.D., Physician to St. Mary's Hospital, Manchester, England. Third Edition. With i8 Illustrations. i2mo. Cloth, .75 BY the same AUTHOR. A Manual for Monthly Nurses. Third Edi- tion. 32mo. Cloth, .40 "This small volume is written as a supplement to the author's well-known work on nursing. It treats only of the conditions of pregnancy and labor. It is clear in its statements, and will prove of great value to those whose duty it is to care for women during and after confinement." — N. Y. Medical Journal. DOMVILLE. Manual for Nurses and Others Engaged in Attending to the Sick. By Ed. J. DoM- viLLE, M.D. Eighth Edition. With Directions for Bandaging, Preparing and Administering Enemata, Fomentations, Poultices, Baths, etc.. Recipes for Sick-room Cookery, Tables of Weights, and a Com- plete Glossary of Medical Terms. Cloth, .75 BOOKS ON NURSING CAN FIELD. The Hygiene of the Sick-Room. A Book for Nurses and Others, being a Brief Consid- eration of Asepsis, Disinfection, Bacteriology, Im- munity, Heating and Ventilation, and Kindred Sub- jects, for the use of Nurses and Other Intelligent Women. By Wm. Buckingham Canfield, a.m., M.D., Lecturer on Clinical Medicine, and Chief of Chest Clinic, University of Maryland, Visiting Phy- sician to Bay View Hospital, etc. i2mo. 247 pages. Handsome Cloth Binding, $1.25 *^* This book is the outcome of a series of lectures delivered by Dr. Canfield at the University of Maryland Training School for Nurses. It contains much valuable information not included in the regular text-books, but which of necessity the nurse should be ac- quainted with. •* We recommend it to the attention, not only of sick-nurses, but also all other persons, of either sex, who desire a knowledge of the behavior of disease, as it concerns infection ; and the manner in which foulness, either of wounded sur- faces, or of the sick-room, or of the dwelling-house, may be prevented. " Each disease is taken up in turn (typhoid fever, consumption, diphtheria, etc.) and the methods of management of the discharges, etc , are described in detail. The formulae for the preparation of disinfecting solutions, for clothing, utensils, privies, etc., are clearly set forth; such details as one may search his library in vain for are here given in a compact form. " The prevention of blindness in infants receives full attention. Ventilation is duly considered, and a chapter is given to the thoughtful discussion of immu- nity and protection from disease. The book closes with some remarks upon the diet of the sick-room. We congratulate Dr. Canfield on his work. It is well worth the moderate price." — Maryland Medical Journal. WESTLAND. The Wife and Mother. A Medical Guide to the Care of her Health and the Management of her Children. By Albert West- land, M.D. i2mo. Illustrated. Cloth, ^1.50 From The Medical News. " . . . Altogether the book fulfils the objects for which it was written, and will materially assist the young married woman in the intelligent perform- ance of new duties." From The Nurse, Boston. " The style is easy and fascinating. It should be in the hands of every nurse and married woman." BOOKS ON MASSAGE KLEEN. Handbook of Massage, Cloth, ^2.25 By Dr. Kleen, of Stockholm and Carlsbad. Translated by Edward M. Hartwell, a.m. m.d., Director of Physi- cal Education, Boston Public Schools, late of Johns Hop- kins University, Baltimore. With an introduction by S. Weir Mitchell, m.d., of Philadelphia. Illustrated by a series of Handsome Engravings, made from fine Pen-and- ink Drawings after original photographs made for the pur- pose. *^* This is the American Edition of " Kleen's Hand- book," which is well known among teachers and experts as the most comprehensive and perfect on the subject. Several changes and additions have been made at the author's suggestion, notably among the latter the set of illustrations made from photographs taken by him for this eaition. No pains have been spared to make this the best of standard works upon massage. MURRELL. Massotherapeutics. Fourth Edi- tion. Or Massage as a Mode of Treatment. By Wm. Murrell, m.d., F.R.C.P., Lecturer on Pharmacology and Therapeutics at Westminster Hospital, Examiner at Uni- versity of Edinburgh, Physician to Royal Hospital for Dis- eases of the Chest. Fifth Edition. Revised and Enlarged. Illustrated. i2mo. Cloth, 1.25 " Dr. Murrell particularly dwells on the importance of discrimination in the selection of eases and on the special qualifications of a competent manipulator. In a word, this essay may be said to convey in a short space most of the infor- mation that is at present available in regard to this popular therapeutic agent. " — FroTH the London Practitioner. " This little volume sets forth clearly all the advantages and disadvantages of massage at the present day, and should be in the hands of every Masseitse or nurse intending to take up the art. The numerous illustrations of the move- ments will prove a great aid. " — From the Trained Nurse . BOOKS ON MASSAGE Massage and the Original Swedish Move- ments. Illustrated. And Their Application to Various Diseases of the Body. A Manual for Students, Nurses, and Physicians. By Kurre W. Ostrom, from the Royal University of Upsala, Sweden ; formerly Instructor in Massage and Swedish Move- ments in the Hospital of the University of Pennsyl- vania and in the Philadelphia Polyclinic and College for Graduates in Medicine, etc. Illustrated by 105 explanatory Wood Engravings. Fourth Edition, Re- vised and Enlarged. i2mo. 168 pages. Cloth, ^i. 00 * " Mr. Ostrom presents to the English public this excellent, systematic manual, showing, by illustrations, the various movements and the mode of application to all parts of the body. The writer tells for what diseases such movements are indicated, with some remarks on the physiology of the movement treatment." ^From The Philadelphia Public Ledger. ** In this volume the author gives an excellent description of the methods of massage and Swedish movement, together with their applicability to various diseased conditions of the body. The methods are rapidly becoming popular- ized in our own country, and the perusal of such a book as Mr, Ostrom has written will be of great advantage to physicians, for whose use it is mainly in- tended."— From the Journal of the American Medical Association. WARD, Notes on Massage; Including Ele- mentary Anatomy and Physiology. By Jessie M. Ward, Instructor in Massage in the Pennsylvania, Philadelphia, Jefferson, and Woman's Hospitals; Clinical Lecturer at Philadelphia Polyclinic. i2mo. Interleaved. Paper cover, ;^i. 00 SURGICAL NURSING BY BERTHA M. VOSWINKEL, Graduate of the Episcopal Hospital, Philadelphia : late Nurse-in-Charge of Children s Hospital, Columbus, O. INCLUDING COMPLETE CHAPTERS ON BANDAGING, DRESSINGS, SPLINTS, ETC. SECOND EDITION-ENLARGED. JUST READY. 112 Illustrations. i2mo. 206 Pages. Cloth, $1.00. Synopsis of Contents. — L Introductory Remarks, Care of Patient, Beds, etc. — IL Qualifications of Surgical Nurse — III. Anti- septics and Antiseptic Surgery — IV. An- tiseptic Dressings — V and VI. Gynecol- ogic Nursing — VII and VIII. Hemor- rhages— IX. Wounds and their Com- plications— X. Fractures, Dislocations, Sprains — XI. Nursing in Special Cases — XII. Bandaging — XIII. Fixed Dress- ings— XIV. Splints and Braces — XV. Massage — Appendix A. Invalid Cookery — Appendix B. Enemas, Ice Poultice, Excessive Perspiration, Weights and Measures, Bichlorid Table, Poisons — Appendix C. Preparation of Patient for Transfusion, Normal Salt Solution, Prei:)aration of Rubber Tissue, Kronig's Method of Sterilizing Catsut — Index. Sample Illustration from Voswiftkel's Surgical Nursing. From The Chicago Medical Recorder. " The book is eminently practical and concise, methods are excellent." The author's style and BOOKS FOR NURSES, HORWITZ'S Surgery. Minor Surgery and Bandaging. Fifth Edition. 167 Illustrations. A Compend of Surgery, including Minor Surgery, Amputations, Fractures, Dislocations, Surgical Dis- eases, Antiseptic Rules, Formulae, etc., with Differen- tial Diagnosis and Treatment, and a Complete Section on Bandaging. By Orville Horwitz, b.s., m.d., Professor of Genito-Urinary Diseases ; late Demonstra- tor of Surgery, Jefferson Medical College, etc. Fifth Edition. 324 pages. 121110. Cloth, .80 * * The new Section on Bandaging and Surgical Dress- ings consists of 34 Pages and 40 Illustrations. Ever^f Bandage of any importance is Figured. POTTER'S Anatomy. Sixth Edition. 117 Illustrations and 16 Lithograph Plates. A Compend of Human Anatomy. By Saml. O. L. Potter, m.a , m.d., m.r.c.p. (Lond.), Professor of the Practice of Medicine, Cooper Medical College, San Francisco. i2mo. Cloth, .80 POTTER'S Materia Medica, Therapeutics, and Prescription Writing. Sixth Edition. Compend of Materia Medica, Therapeutics, and Pre- scription Writing. With special reference to the Phy- siological Action of Drugs. By Samuel O. L. Potter, M.A., M.D., M.R.C.P. (LoND.), late A. A. Surgeon, U. S. Army ; Professor of the Practice of Medicine, Cooper Medical College, San Francisco. 1 2mo. Cloth, .80 BRUBAKER'S Physiology. Ninth Edition, Enlarged and Improved. Illustrated. A Com- pend of Physiology, including Embryology. B)- A. P. Brubaker, m.d., Demonstrator of Physiology at Jefferson Medical College ; Professor of Physiology, Pennsylvania College of Dental Surgery, Philadelphia. 28 Illustrations. 121110. Cloth, .80 FIFTH EDITION ACCIDENTS AND EMERGENCIES. A Manual for the treatment of Surgical and other Injuries, Poisoning and various Medical Emergencies, in the absence of the Physician. By CHARLES W. DULLES, M.D., Surgeon to the Rush Hospital ; formerly Surgeon to the Out-Door Depart- ments of the University and Presbyterian Hospitals, Philadelphia. Fifth Edition, Enlarged. New Illustrations. 12mo. ILLUSTRATED. Cloth, $1.00 SHORT LIST OF CONTENTS. Preliminary Remarks. Obstructions to Respiration. Foreign Bodies in the Eye, Nose and Ear. Fits or Seizures. Injuries to the Brain. Effects of Heat and Cold. Electricity, Accidents caused by. Sprains. Dislocations. Fractures. Wounds of all kinds, including the bites of Dogs, Cats, Snakes, Insects, etc. Railroad and Machinery Accidents. Hemorrhage — Bleeding. Special Hemorrhages. Transportation of the Injured. Poisons and their Antidotes. Domestic Emergencies, includes Chol- era Morbus, Vomitmg, Diarrhoea, Nervous Attacks, Earache, Tooth- ache, Asthmatic Attacks, Croup, etc., etc. Signs of Death. Supplies for Emergencies. The Surgical and Medicine Case, their contents and use. Bandaging, Poultices, etc. Index. *.x.* This book should be in the possession of every head of a family. Nurse, Manufacturer, Police Lieutenant, Sea Captain, Hos- pital Steward, School Teacher, Druggist, etc. etc. " Several attempts have been made to prepare a volume which would serve as a handy manual for' reference in the time of need, in the absence of a doctor, but none have succeeded better than the present little work. It should be in the hands of all officers charged with the public conveyance of passengers, to be read, in preparation for emergencies, and afterward to serve as a book of refer- ence." —North Carolina Medical Journal. " Ihis little manual contains simple directions for the preliminary treatment of accidents to all parts of the body and of such diseases as persons are suddenly seized with. Without profuseness or an unintelligible vocabulary, it contains in a small space a deal of useful information." — J\lew York IVorld. " This is a revised and enlarged edition, with new illustrations, of the manual, explaining the treatment of surgical and other injuries in the absence of the phy- sician. The simple and practical suggestions of this little book should be known to every one. Accidents are constantly occurring, and a knowledge of what should be done in an emergency is very valuable. Such a handbook should be in every home, placed where it can always be found readily. — Boston Journal of Education. NURSES' CHARTS, GRIFFITH'S Temperature Charts. A concise, complete Record of PulsC; Respiration, Temperature, etc. Packets of fifty, 50 cents KEEN'S Clinical Charts. A Series of Outline Drawings of the Human Body, on which may be marked the Course of Disease, Fractures, Operations, etc. Pads of fifty, $1.00 SCHREINER'S Diet List. Arranged in the Form of a Chart, on which Articles of Diet may be indi- cated for any Disease. Pads of fifty, 75 cents BROWN. ELEMENTARY PHYSIOLOGY FOR NURSES, BY FLORENCE HAIG-BROWN, Si. TAo/nas' Hospital, London. 21 Illustrations. 12ino. Cloth, 75 Cents. Based upon the Lectures given to nurses by the Medical Officers of St. Thomas' Hospital. LECTURES ON MEDICINE TO NURSES, BY HERBERT CUFF, M. D., Assistant Medical Officer Southwestern Fever Hospital, London. Second Edition. 12ino. Illustrated. Cloth, $1.26. Synopsis of Contents. — Infection — Use of Stimulants — Feeding— The Pulse — Inflammation— Pneumonia — Enteric Fever — Scarlet Fever— Diphtheria — Measles— Whooping Cough— Paralysis — Hysteria — Internal Hemorrhages — Massage— Precautions in In- fectious Disease. THE American Health Primers. EDITED BY W. W. KEEN, M.D., Professor of Surgery in the Jefferson Medical College, Fellow of the Colleg^e of Physicians of Philadelphia, etc. 12 Vols. 32mo. Attractive Cloth Binding, each 40 Cents. This Series of Health Primers is prepared to diffuse as widely and cheaply as possible, among all classes, a knowledge of the elementary facts of Preventive MediciHe. They are intended incidentally to assist in curing dis- eases, and to teach people how to form correct habits of living, and take care of themselves, their children, employees, etc. I. HEARING AND HOW TO KEEP IT. With Illustrations. By Chas. H. BuRiNKTT, M D., of Philadelphia, Aurist to the Presbyterian HospitaL II. LONG LIFE AND HOW TO REACH IT. By J. G. Richardson, m.d., of Philadelphia, late Professor of Hygiene in the University of Pennsyl- vania. III. THE SUMMER AND ITS DISEASES. By James C. Wilson, m.d., of Philadelphia, Professor of the Practice of Medicine, Jefferson Medical College. IV. EYESIGHT AND HOW TO CARE FOR IT. With Illustrations. By George C. Harlan, m.d., of Philadelphia, Surgeon to the Wills (Eye) Hospital. V. THE THROAT AND THE VOICE. With Illustrations. By J. Solis Cohen, m d., of Philadelphia, Lecturer on Diseases of the Throat in Jef- ferson Medical College, and on the Voice in the National School of Oratory. VI. THE WINTER AND ITS DANGERS. By Hamilton Osgood, m.d., of Boston, Editorial Staff Boston Medical and Surgical Journal. VII. THE MOUTH AND THE TEETH. With Illustrations. By J. W. White, m.d., d.d.s,, of Philadelphia, Editor of the Dental Cosmos. VIII. BRAIN WORK AND OVERWORK. By H. C. Wood, Jr., m.d, of Philadelphia, CUnical Professor of Nervous Diseases in the University of ^^ Pennsylvania. iX. OUR HOMES. With Illustrations. By Henry Hartshorns, m.d., of Philadelphia, formerly Professor of Hygiene in the University of Penn- sylvania. X. THE SKIN IN HEALTH AND DISEASE. With Illustrations. By L. D. Bulkley, m.d., of New York, Physician to the Skin Department of the New York Hospital. XL SEA AIR AND SEA BATHING. With Hlustrations. By John H. Packard, m.d , of Philadelphia, Surgeon to the Pennsylvania Hospital. XIL SCHOOL AND INDUSTRIAL HYGIENE. By D. F. Lincoln, m.d., of Boston, Mass., Chairman Department of Health, American Social Science Association. •' The series of 'American Health Primers ' deserves hearty commendation. These handbooks of practical suggestions are prepared by men whose profes- sional competence is beyond question, and, for the most part, by those who have made the subject treated the study of their lives." — Ne7u York Sun. *«* Each Volume 40 Cents, in Attractive Cloth Binding. THE Hygiene of the Nursery INCLUDING THE GENERAL REGIMEN AND FEEDING OF INFANTS AND CHILDREN AND THE DOMESTIC MANAGEMENT OF THE ORDINARY EMERGENCIES OF EARLY LIFE. BY LOUIS STARR, M. D., Clinical Professor of Diseases of Children in the Hospital of the University of Pennsylvania: Physician to the Children's Hospital, Phila. Sixth Edition. Enlarged and improved. WITH TWENTY-FIVE ILLUSTRATIONS. i2mo. 280 Pages. Cloth, $1.00. *^* This book contains very complete directions for the proper feeding of infants : 1st, From the maternal breast. 2d. By wet- nurse, including rules for choosing the woman. 3d, Artificial Feeding. This part of the subject is elaborated carefully, so as to include everything of importance, and will be found of great service to the monthly nurse. General and specific rules for feeding are given, and Diet Lists from the first week up to the eighteenth month, with various recipes for artificial foods, peptonized milk, etc. Directions for the sterilization of milk, substitutes for milk, prepara- tion of food for both well and sick children, nutritious enemata. etc, and the general management of the Nursery. " Dr. Starr's experience as Clinical Professor of Diseases of Children in the University Hospital and as physician to the Children's Hospital, with his eminence in private practice among juvenile patients, is ample warranty for the satisfaction and instruction to be found in this book. The dedication " To my Little Patients," shows the sympathy with which the writer enters upon the important discussion. The volume is entirely in the modern lines of preventive medicine— more important in the nursery than at any other time of life ; because constitution building is going on then and there. In this admirable treatise, so clearly written that no mother need be deterred by fear of medical terms from making its teaching her own, Dr. Starr carries out the highest ideal of the modem physician, so to regulate the lives of his professional clients that the occasions are less frequent when he need be called in to act for serious compli- cations. * * * * With the numerous good treatises on the subject that JPhiladelphia publications include, this intelligent work is the most distinguished, as it is also the latest work on complete Hygiene of the Nursery." — The Led- ^er, Philadelphia. A NEW EDITION, JUST READY. GOULD'S POCKET MEDICAL LEXICON. 21,000 MEDICAL WORDS PRONOUNCED AND DEFINED. A Pronouncing Lexicon of Medical Words Specially Adapted £oc Nurses, Including Many Useful Tables and a Dose List. BY GEORGE M. GOLID. M.D., Author of "An Illustrated Dictionary of Medi- cine, Biology, and Allied Sciences," "The Student's Medical Dictionary," etc. Pocket Size. 522 Pages. Gilt Edges, Full Morocco. Price $1.00; with a Thumb Index, $1.25. OVER 90,000 COPIES OF GOULD'S DICTIONARIES HAVE BEEN SOLD. " Gould's Dictionary, Pocket Edition, is the most complete and convenient I have seen," — Marion E. Smith, Head Nurse , Philadelphia Hospital, Phila. " The Pocket Dictionary is a little gem." — L. J. Gross, Head Nurse, Buffalo General Hospital. " I have examined Gould's Dictionary, and consider it the best dictionary in a small compass that I have seen. The price, too, is most reasonable I shall recommend it to all our nurses." — F. Hutcheson , Head Nurse, Flower Mission Training School for Nurses, Indianapolis, Ind. " 1 shall certainly have the nurses each send for a copy of tbe dictionary. It is just what they need, and is a nice size to carry." — Harriet Sutherland, Head Nurse, Margaret Pillsbury Hospital, Concord, N. H. «^ Every nurse should have a copy 'of this little book in order to intelligently pursue her studies and to thoroughly understand the physician's directions. It furnishes a vast amount of informa- tion not to be obtained in the regular text-books. BRIGHAM YOUNG UNIVERSITY 3 1197 21977 1661 Date Due ikiSJtt %S I -.19 um if fwn m jA. ^p^^P*§55 W*' ?^ -• r,[ 480fi .-^*<. ^ 4i8S. iftAR-^ znPR i 3 0 196& fums^^eF